NPIMap

Organization Active NPI

Pathology Services Laboratory PA

  • Anatomic Pathology & Clinical Pathology Physician
  • Russellville, AR
National Provider Identifier
1831158369
Registry record updated May 31, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X
Legal business name
PATHOLOGY SERVICES LABORATORY PA
Practice address
1430 West C Street
Russellville, AR 72801
Phone
(479) 968-6781
Fax
(479) 968-3074
NPI assigned
Mar 22, 2006
Last updated
May 31, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 31, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Christina A Jetton, MDNPI 1205895745
Title
President
Phone
(479) 968-6781

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Anatomic Pathology & Clinical Pathology Physician 207ZP0102X NU Primary

Addresses

Primary practice location

1430 West C Street
Russellville, AR 72801

Mailing address

PO Box 925
Russellville, AR 72811
Phone (479) 968-6781

Other identifiers 2

IdentifierTypeStateIssuer
770091902OtherARBREASTCARE
103882709MedicaidAR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080228000782 AR Part B Supplier - Clinic/Group Practice 0840373411 Receives reassigned benefits from 11 practitioners
Practice locations: Russellville, AR

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D0468992Pathology Services Laboratory PA1430 West C Street, Russellville, AR 72801ComplianceMay 18, 2027

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1142985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1717113600000",
    "number": "1831158369",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 925",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "72811",
            "telephone_number": "479-968-6781",
            "fax_number": "479-968-3074"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1430 WEST C STREET",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "72801",
            "telephone_number": "479-968-6781",
            "fax_number": "479-968-3074"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PATHOLOGY SERVICES LABORATORY PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-22",
        "last_updated": "2024-05-31",
        "certification_date": "2024-05-31",
        "status": "A",
        "authorized_official_last_name": "JETTON",
        "authorized_official_first_name": "CHRISTINA",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "479-968-6781",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BREASTCARE",
            "identifier": "770091902",
            "state": "AR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103882709",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Russellville, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 31, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.