Healthcare Provider Details

I. General information

NPI: 1669637773
Provider Name (Legal Business Name): HARDMAN PATHOLOGY ADX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 TRINITY PL
ATHENS GA
30607-2118
US

IV. Provider business mailing address

110 TRINITY PL
ATHENS GA
30607-2118
US

V. Phone/Fax

Practice location:
  • Phone: 706-546-4884
  • Fax:
Mailing address:
  • Phone: 706-546-4884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number029-027
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number029-027
License Number StateGA

VIII. Authorized Official

Name: MR. MARTIN STEFANELLI
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 561-626-5512