Basic Information
| Provider Information | |||||||||
| NPI: | 1609842111 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWESTERN PATHOLOGY ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 WOODCHASE | ||||||||
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| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302409734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068453175 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2122 MANCHESTER EXPY | ||||||||
| Address2: | ST. FRANCIS HOSPITAL LABORATORY | ||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319046878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065964100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 11/14/2007 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7065964100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | CI9362 | 01 | GA | RAILROAD MEDICARE | OTHER |