Provider Demographics
NPI:1164669388
Name:TRI COUNTY PATHOLOGY ASSOCIATES LAB
Entity Type:Organization
Organization Name:TRI COUNTY PATHOLOGY ASSOCIATES LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HANY
Authorized Official - Middle Name:
Authorized Official - Last Name:BISHARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-424-7800
Mailing Address - Street 1:PO BOX 60280
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-0280
Mailing Address - Country:US
Mailing Address - Phone:770-424-7800
Mailing Address - Fax:
Practice Address - Street 1:833 CAMPBELL HILL ST NW
Practice Address - Street 2:SUITE 111
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1134
Practice Address - Country:US
Practice Address - Phone:770-424-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI COUNTY PATHOLOGY ASSOCIATES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-09
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00061652AMedicaid
GA69WBDLBMedicare PIN