1760768329 NPI number — GOLDEN TRIANGLE PATHOLOGY

Table of content: (NPI 1760768329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760768329 NPI number — GOLDEN TRIANGLE PATHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN TRIANGLE PATHOLOGY
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:
1760768329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2906
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38655-2925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-362-0858
Provider Business Mailing Address Fax Number:
662-534-7188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2520 5TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39705-2008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-362-0858
Provider Business Practice Location Address Fax Number:
662-534-7188
Provider Enumeration Date:
10/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FULLENWIDER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
800-362-0858

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: 02622338 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: DS3144 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com