Healthcare Provider Details

I. General information

NPI: 1104887330
Provider Name (Legal Business Name): GWINNETT PATHOLOGY ASSOC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD PATHOLOGY DEPT
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

PO BOX 1686
INDIANAPOLIS IN
46206-1686
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-4524
  • Fax: 770-682-2219
Mailing address:
  • Phone: 706-232-0156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: RICARDO J DELGADO
Title or Position: PRESIDENT
Credential: MD
Phone: 678-312-4524