Provider Demographics
NPI:1942865480
Name:COLQUITT REGIONAL PATHOLOGY, LLC
Entity Type:Organization
Organization Name:COLQUITT REGIONAL PATHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:FITCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-985-5675
Mailing Address - Street 1:PO BOX 2862
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2862
Mailing Address - Country:US
Mailing Address - Phone:229-985-5675
Mailing Address - Fax:229-985-5675
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-985-3420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLQUITT REGIONAL MEDICAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-09
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003220270AMedicaid