1649494816 NPI number — PATHOLOGY AND LABORATORY MEDICINE, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649494816 NPI number — PATHOLOGY AND LABORATORY MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY AND LABORATORY MEDICINE, PC
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:
1649494816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 BUCKEYE RD
Provider Second Line Business Mailing Address:
SUITE 178
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30341-4229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-458-6103
Provider Business Mailing Address Fax Number:
770-234-0437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 JOHNSON FERRY RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-1606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-458-6103
Provider Business Practice Location Address Fax Number:
770-234-0437
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WELLS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF PATHOLOGIST
Authorized Official Telephone Number:
770-458-6103

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CB5863 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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