Basic Information
Provider Information | |||||||||
NPI: | 1316185382 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLQUITT PATHOLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 304 SUNSET CIR STE C | ||||||||
Address2: | P O BOX 2047 | ||||||||
City: | MOULTRIE | ||||||||
State: | GA | ||||||||
PostalCode: | 317762047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2299855675 | ||||||||
FaxNumber: | 2299855675 | ||||||||
Practice Location | |||||||||
Address1: | 304 SUNSET CIR STE C | ||||||||
Address2: |   | ||||||||
City: | MOULTRIE | ||||||||
State: | GA | ||||||||
PostalCode: | 317686930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2299855675 | ||||||||
FaxNumber: | 2299855675 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2009 | ||||||||
LastUpdateDate: | 02/19/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOSER | ||||||||
AuthorizedOfficialFirstName: | ANTHONY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2299855675 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 046462 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.