Provider Demographics
NPI:1861486904
Name:PATHOLOGY ASSOCIATES OF WAYCROSS
Entity Type:Organization
Organization Name:PATHOLOGY ASSOCIATES OF WAYCROSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:P
Authorized Official - Last Name:MIRMOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-287-1515
Mailing Address - Street 1:PO BOX 1409
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31502-1409
Mailing Address - Country:US
Mailing Address - Phone:706-287-1515
Mailing Address - Fax:912-287-1394
Practice Address - Street 1:410 DARLING AVE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5246
Practice Address - Country:US
Practice Address - Phone:912-287-1515
Practice Address - Fax:912-287-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID #