Provider Demographics
NPI:1801083316
Name:UPSTATE PATHOLOGY, PA
Entity type:Organization
Organization Name:UPSTATE PATHOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:864-322-4167
Mailing Address - Street 1:PO BOX 9280
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29604-9280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3955
Practice Address - Country:US
Practice Address - Phone:864-322-4167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0741Medicaid
SCGP0741Medicaid