Basic Information
| Provider Information | |||||||||
| NPI: | 1417923228 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN PATHOLOGY ASSOCIATES INC | ||||||||
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| OtherOrganizationName: | SOUTHERN PATHOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51530 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379501530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655882928 | ||||||||
| FaxNumber: | 8654509374 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 MCCALLIE AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374043258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234931550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LANHAM | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4234931552 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | TN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 3386039 | 05 | TN | MEDICAID | CA5133 | 01 | TN | RR MCARE-TN | OTHER |