Provider Demographics
NPI:1467502716
Name:OCMULGEE MEDICAL PATHOLOGY ASSOCIATION INC
Entity Type:Organization
Organization Name:OCMULGEE MEDICAL PATHOLOGY ASSOCIATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-275-8072
Mailing Address - Street 1:2560 N SHADELAND AVE STE A
Mailing Address - Street 2:ATTN: ANN PATTERSON
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-1706
Mailing Address - Country:US
Mailing Address - Phone:317-275-8072
Mailing Address - Fax:317-275-8124
Practice Address - Street 1:350 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3838
Practice Address - Country:US
Practice Address - Phone:478-765-4865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIPATH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-11
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D0982593291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA591654749AMedicaid
GA11D0982593OtherCLIA