Provider Demographics
NPI:1821100892
Name:GA CELL AND TISSUE DIAGNOSTIC CENTER INC.
Entity Type:Organization
Organization Name:GA CELL AND TISSUE DIAGNOSTIC CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:STATON
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-273-4956
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31010-0568
Mailing Address - Country:US
Mailing Address - Phone:229-273-4956
Mailing Address - Fax:
Practice Address - Street 1:902 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3234
Practice Address - Country:US
Practice Address - Phone:229-276-3342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032934291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000532111BMedicaid
GADG5747OtherRAILROAD MEDICARE
GAGRP8160Medicare PIN
GAB91694Medicare UPIN