Provider Demographics
NPI:1376641290
Name:DEKALB PATHOLOGY PC
Entity Type:Organization
Organization Name:DEKALB PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:MCNEILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-501-6700
Mailing Address - Street 1:PO BOX 1457
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-1457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 NORTH DECATUR ROAD
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:404-501-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300033614AMedicaid
CN5005OtherRAILROAD MEDICARE
GAGRP3042Medicare PIN