Provider Demographics
NPI:1780656363
Name:PROVIDENCE PATHOLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:PROVIDENCE PATHOLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MODZELEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-256-5335
Mailing Address - Street 1:PO BOX 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-0309
Mailing Address - Country:US
Mailing Address - Phone:843-554-9300
Mailing Address - Fax:843-556-8780
Practice Address - Street 1:2435 FOREST DR
Practice Address - Street 2:C/O PROVIDENCE HOSPITAL
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2026
Practice Address - Country:US
Practice Address - Phone:803-256-5335
Practice Address - Fax:803-256-5454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19654207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2746Medicaid
SCCG6293Medicare PIN
SCGP2746Medicaid