Provider Demographics
NPI:1760428247
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:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-697-8378
Mailing Address - Street 1:14275 MIDWAY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:866-836-7136
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:2275 NORTHWEST PKWY SE
Practice Address - Street 2:SUITE 140
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9321
Practice Address - Country:US
Practice Address - Phone:770-951-1793
Practice Address - Fax:770-613-3380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIPATH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-21
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D1004139291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA591654749BMedicaid
SCL00204Medicaid
GA591654749BMedicaid
GA591654749BMedicaid
GA69WBDLPMedicare PIN