1629023098 NPI number — PATHOLOGY ASSOCIATES OF VALDOSTA, P.C.

Table of content: (NPI 1629023098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629023098 NPI number — PATHOLOGY ASSOCIATES OF VALDOSTA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY ASSOCIATES OF VALDOSTA, P.C.
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:
Provider Other Organization Name Type Code:
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:
1629023098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3287
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31604-3287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-245-0447
Provider Business Mailing Address Fax Number:
229-245-0448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 N PATTERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31602-2944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-245-0447
Provider Business Practice Location Address Fax Number:
229-245-0448
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
229-245-0447

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  J307285 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: N357819 . This is a "MEDICAID WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: CF4854 . This is a "RR MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 017953200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com