Provider Demographics
NPI:1528030368
Name:AMERIPATH SC INC
Entity Type:Organization
Organization Name:AMERIPATH SC INC
Other - Org Name:MAIZE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-550-3003
Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:214-932-8029
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:266 W COLEMAN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5651
Practice Address - Country:US
Practice Address - Phone:843-388-6911
Practice Address - Fax:843-388-6917
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIPATH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42D2039111291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00106241OtherRR MCR
GA922194685AMedicaid
SCL00169Medicaid
VA010252296Medicaid
WV3810004199Medicaid
NC7001264Medicaid
SCQ333250001Medicare PIN
WV3810004199Medicaid