Provider Demographics
NPI:1609842111
Name:SOUTHWESTERN PATHOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SOUTHWESTERN PATHOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-596-4100
Mailing Address - Street 1:102 WOODCHASE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-9734
Mailing Address - Country:US
Mailing Address - Phone:706-845-3175
Mailing Address - Fax:
Practice Address - Street 1:2122 MANCHESTER EXPY
Practice Address - Street 2:ST. FRANCIS HOSPITAL LABORATORY
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6878
Practice Address - Country:US
Practice Address - Phone:706-596-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACI9362OtherRAILROAD MEDICARE
GAGRP3388Medicare PIN