MEDICARE: PATHOLOGY ASSOCIATES OF CENTRAL MISSISSIPPI, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician

General Provider Information

NPI Number	:	1215330790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHOLOGY ASSOCIATES OF CENTRAL MISSISSIPPI, LLC

Provider Business Mailing Address
First Line	:	969 LAKELAND DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39216-4606
Country	:	US
Telephone Number	:	601-200-3840
Fax Number	:	601-200-8801

Provider Business Practice Location Address
First Line	:	5700 SOUTHWYCK BLVD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-1509
Country	:	US
Telephone Number	:	800-288-8325
Fax Number	:	419-866-5453

Authorized Official
Title or Position	:	AUTHORIZED SIGNER
Name	:	RANDALL S SMITH
Credential	:	MD
Telephone Number	:	601-200-3840

Provider Enumeration Date	:	09/29/2014
Last Update Date	:	09/29/2014

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