Basic Information
| Provider Information | |||||||||
| NPI: | 1265502520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIETTA GYNECOLOGIC ASSOCIATES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MGA LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457502115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403743622 | ||||||||
| FaxNumber: | 7403744209 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457502115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403743622 | ||||||||
| FaxNumber: | 7403744209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LINES | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7403743622 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | OH | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 2487205 | 05 | OH | MEDICAID | 0006831001 | 05 | WV | MEDICAID |