Basic Information
Provider Information | |||||||||
NPI: | 1295786788 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMERIPATH MISSISSIPPI INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7111 FAIRWAY DR | ||||||||
Address2: | SUITE 400 | ||||||||
City: | PALM BEACH GARDENS | ||||||||
State: | FL | ||||||||
PostalCode: | 334184204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617126265 | ||||||||
FaxNumber: | 5617127349 | ||||||||
Practice Location | |||||||||
Address1: | 306 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | MS | ||||||||
PostalCode: | 397051935 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6623271262 | ||||||||
FaxNumber: | 6623280338 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DILLEMUTH | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | ASST SEC / ASST. TREASURER | ||||||||
AuthorizedOfficialTelephone: | 5617126200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   | MS | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.