Provider Demographics
NPI:1417923228
Name:SOUTHERN PATHOLOGY ASSOCIATES INC
Entity Type:Organization
Organization Name:SOUTHERN PATHOLOGY ASSOCIATES INC
Other - Org Name:SOUTHERN PATHOLOGY ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LANHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-493-1552
Mailing Address - Street 1:PO BOX 51530
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-1530
Mailing Address - Country:US
Mailing Address - Phone:865-588-2928
Mailing Address - Fax:865-450-9374
Practice Address - Street 1:2333 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3258
Practice Address - Country:US
Practice Address - Phone:423-493-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3386039Medicaid
TNCA5133OtherRR MCARE-TN
GAGRP440Medicare PIN
TNCA5133OtherRR MCARE-TN
TN3386039Medicare PIN
TN3386570Medicare PIN