Provider Demographics
NPI:1760768329
Name:GOLDEN TRIANGLE PATHOLOGY
Entity Type:Organization
Organization Name:GOLDEN TRIANGLE PATHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FULLENWIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-362-0858
Mailing Address - Street 1:PO BOX 2906
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-2925
Mailing Address - Country:US
Mailing Address - Phone:800-362-0858
Mailing Address - Fax:662-534-7188
Practice Address - Street 1:2520 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2008
Practice Address - Country:US
Practice Address - Phone:800-362-0858
Practice Address - Fax:662-534-7188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02622338Medicaid
DS3144OtherRAILROAD MEDICARE
MS02622338Medicaid