Provider Demographics
NPI:1588623110
Name:PEACHTREE LABORATORY ASSOCIATES PC
Entity type:Organization
Organization Name:PEACHTREE LABORATORY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:H
Authorized Official - Last Name:DUPUIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-605-2054
Mailing Address - Street 1:PO BOX 491028
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049-0053
Mailing Address - Country:US
Mailing Address - Phone:404-605-2054
Mailing Address - Fax:404-609-6766
Practice Address - Street 1:1984 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1298
Practice Address - Country:US
Practice Address - Phone:800-288-8325
Practice Address - Fax:404-609-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300028335AMedicaid