Basic Information
| Provider Information | |||||||||
| NPI: | 1962474700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERIPATH MISSISSIPPI INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7111 FAIRWAY DRIVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334184207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617126200 | ||||||||
| FaxNumber: | 5617127349 | ||||||||
| Practice Location | |||||||||
| Address1: | 1033 N FLOWOOD DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019328370 | ||||||||
| FaxNumber: | 6019392915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 01/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6105503000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 25D0651861 | MS | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 00015623 | 05 | MS | MEDICAID | 1918130 | 05 | LA | MEDICAID |