Provider Demographics
NPI:1558318162
Name:STATESBORO PATHOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:STATESBORO PATHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:CARICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-489-2400
Mailing Address - Street 1:PO BOX 2697
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-2697
Mailing Address - Country:US
Mailing Address - Phone:912-678-1668
Mailing Address - Fax:
Practice Address - Street 1:112 S ZETTEROWER AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4816
Practice Address - Country:US
Practice Address - Phone:912-489-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA22BDGNQMedicare ID - Type Unspecified