Provider Demographics
NPI:1003823196
Name:WEST GEORGIA PATHOLOGY, LLC
Entity Type:Organization
Organization Name:WEST GEORGIA PATHOLOGY, LLC
Other - Org Name:WGP
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRATTENDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-626-5512
Mailing Address - Street 1:11025 RCA CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4269
Mailing Address - Country:US
Mailing Address - Phone:561-514-5822
Mailing Address - Fax:561-626-4530
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:ATTENTION: PATHOLOGY DEPARTMENT
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:678-305-9046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7859Medicare PIN