Basic Information
| Provider Information | |||||||||
| NPI: | 1538368501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCMULGEE MEDICAL PATHOLOGY ASSOCIATION INC | ||||||||
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| OtherOrganizationName: | ATLANTA GI | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328029 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 1777 MONTREAL CIR STE A-C | ||||||||
| Address2: | |||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300846802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784061289 | ||||||||
| FaxNumber: | 7706217530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 03/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOLAN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8666978378 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
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| NPICertificationDate: | 03/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 11D1066992 | GA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 11D2230489 | 01 | CLIA | OTHER |