Basic Information
| Provider Information | |||||||||
| NPI: | 1073585774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHOLOGY ASSOCIATES OF ST. THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30309 | ||||||||
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| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294170309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435549300 | ||||||||
| FaxNumber: | 8435668780 | ||||||||
| Practice Location | |||||||||
| Address1: | 4220 HARDING RD | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152226756 | ||||||||
| FaxNumber: | 6152226883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 01/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCDONALD | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | CLAYTON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6152226756 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D, | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 39425 | TN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ZC0500X | 8814 | TN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZH0000X | 20647 | TN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZM0300X | 8773 | TN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology | 207ZP0102X | 8814 | TN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 3701748 | 05 | TN | MEDICAID |