Basic Information
| Provider Information | |||||||||
| NPI: | 1801862404 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHOLOGY ASSOCIATES OF SOUTHERN OH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431300550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406875164 | ||||||||
| FaxNumber: | 7406541417 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 N EWING ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406877141 | ||||||||
| FaxNumber: | 7406878973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | GOGATE | ||||||||
| AuthorizedOfficialFirstName: | SHASHIKALA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7406878141 | ||||||||
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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 | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 2039583 | 05 | OH | MEDICAID |