Provider Demographics
NPI:1457510273
Name:CHARLESTON PATHOLOGY PA
Entity Type:Organization
Organization Name:CHARLESTON PATHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:WORSHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-724-2068
Mailing Address - Street 1:PO BOX 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-0309
Mailing Address - Country:US
Mailing Address - Phone:843-554-9300
Mailing Address - Fax:843-566-8780
Practice Address - Street 1:1200 JOHNNIE DODDS BLVD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3231
Practice Address - Country:US
Practice Address - Phone:843-724-2068
Practice Address - Fax:843-727-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207ZC0500X, 207ZD0900X, 207ZH0000X, 207ZP0101X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Single Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC2136Medicaid
SCCB4465Medicare PIN
SCPC2136Medicaid