1497888499 NPI number — PATHOLOGY LAB OF GEORGIA, LLC

Table of content: (NPI 1497888499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497888499 NPI number — PATHOLOGY LAB OF GEORGIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY LAB OF GEORGIA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PODIATRY PATHOLOGY LAB OF GEORGIA LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497888499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 CIRCLE 75 PARKWAY
Provider Second Line Business Mailing Address:
SUITE 900
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-3084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-384-0284
Provider Business Mailing Address Fax Number:
404-446-1957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
428 WINN CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30030-1726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-917-1770
Provider Business Practice Location Address Fax Number:
404-446-0296
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HELFMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
770-384-0284

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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