Basic Information
Provider Information
NPI: 1164486700
EntityType: 2
ReplacementNPI:  
OrganizationName: ORANGEBURG PATHOLOGY ASSOCIATES PA
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Mailing Information
Address1: PO BOX 52990
Address2:  
City: GREENWOOD
State: SC
PostalCode: 296490048
CountryCode: US
TelephoneNumber: 8642233600
FaxNumber: 8642236054
Practice Location
Address1: 3000 SAINT MATTHEWS RD
Address2:  
City: ORANGEBURG
State: SC
PostalCode: 291181442
CountryCode: US
TelephoneNumber: 8035332418
FaxNumber: 8035334638
Other Information
ProviderEnumerationDate: 04/12/2006
LastUpdateDate: 04/17/2008
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: FANT
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName: ALEXANDER
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 8035332418
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207ZP0102X17118SCY193400000X MULTIPLE SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology

ID Information
IDTypeStateIssuerDescription
GP331105SC MEDICAID


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