Basic Information
| Provider Information | |||||||||
| NPI: | 1861460248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHOLOGY AND LABORATORY CONSULTANTS OF ATHENS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 491270 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702374500 | ||||||||
| FaxNumber: | 7702374539 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 BAXTER ST | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063892425 | ||||||||
| FaxNumber: | 7703892426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 02/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | GAINES | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES | ||||||||
| AuthorizedOfficialTelephone: | 7063892425 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | CN8205 | 01 | GA | RAILROAD MEDICARE | OTHER |