Basic Information
Provider Information | |||||||||
NPI: | 1164486700 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORANGEBURG PATHOLOGY ASSOCIATES PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FANT | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8035332418 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 17118 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | GP3311 | 05 | SC |   | MEDICAID |