Basic Information
| Provider Information | |||||||||
| NPI: | 1467502716 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCMULGEE MEDICAL PATHOLOGY ASSOCIATION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2560 N SHADELAND AVE STE A | ||||||||
| Address2: | ATTN: ANN PATTERSON | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462191706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172758072 | ||||||||
| FaxNumber: | 3172758124 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787654865 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 12/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 3172758072 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 11D0982593 | GA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 591654749A | 05 | GA | MEDICAID | 11D0982593 | 01 | GA | CLIA | OTHER |