Provider Demographics
NPI:1346249448
Name:KANAWHA PATHOLOGY ASSOCIATES INC
Entity Type:Organization
Organization Name:KANAWHA PATHOLOGY ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:FULKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-766-3560
Mailing Address - Street 1:PO BOX 9129
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-0129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4605 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-766-3560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0008272000Medicaid
DA0748OtherRAILROAD MEDICARE
DA0748OtherRAILROAD MEDICARE