Provider Demographics
NPI:1154650091
Name:SYNTHESIS PATHOLOGY, LLC
Entity Type:Organization
Organization Name:SYNTHESIS PATHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GIBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-464-2600
Mailing Address - Street 1:610 3RD ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3294
Mailing Address - Country:US
Mailing Address - Phone:478-464-2600
Mailing Address - Fax:478-464-2604
Practice Address - Street 1:610 3RD ST
Practice Address - Street 2:SUITE 206
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3294
Practice Address - Country:US
Practice Address - Phone:478-464-2600
Practice Address - Fax:478-464-2604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D1104616OtherCLIA