Provider Demographics
NPI:1265502520
Name:MARIETTA GYNECOLOGIC ASSOCIATES INC
Entity Type:Organization
Organization Name:MARIETTA GYNECOLOGIC ASSOCIATES INC
Other - Org Name:MGA LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-374-3622
Mailing Address - Street 1:410 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-2115
Mailing Address - Country:US
Mailing Address - Phone:740-374-3622
Mailing Address - Fax:740-374-4209
Practice Address - Street 1:410 2ND ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2115
Practice Address - Country:US
Practice Address - Phone:740-374-3622
Practice Address - Fax:740-374-4209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2487205Medicaid
WV0006831001Medicaid
OH2487205Medicaid
WV9371911Medicare PIN