Provider Demographics
NPI:1043271273
Name:DIAGNOSTIC PATHOLOGY SERVICES PA
Entity Type:Organization
Organization Name:DIAGNOSTIC PATHOLOGY SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-305-4285
Mailing Address - Street 1:PO BOX 491240
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049
Mailing Address - Country:US
Mailing Address - Phone:770-751-2529
Mailing Address - Fax:770-751-2723
Practice Address - Street 1:1170 CLEVELAND AVENUE
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344
Practice Address - Country:US
Practice Address - Phone:404-305-4285
Practice Address - Fax:404-305-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACC0645Medicare ID - Type UnspecifiedRAILROAD
GA=========AMedicare PIN