Provider Demographics
NPI:1720053309
Name:SPARTANBURG PATHOLOGY CONSULTANTS PA
Entity Type:Organization
Organization Name:SPARTANBURG PATHOLOGY CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WRENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-560-6217
Mailing Address - Street 1:PO BOX 52990
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-0048
Mailing Address - Country:US
Mailing Address - Phone:864-223-3600
Mailing Address - Fax:864-223-6054
Practice Address - Street 1:106 VENTURE BLVD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3805
Practice Address - Country:US
Practice Address - Phone:864-560-6217
Practice Address - Fax:864-560-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21725207ZD0900X
SC10037207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0384Medicaid
SCGP0384Medicaid
SCQ33464001Medicare PIN