Healthcare Provider Details

I. General information

NPI: 1467502716
Provider Name (Legal Business Name): OCMULGEE MEDICAL PATHOLOGY ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HOSPITAL DR
MACON GA
31217-3838
US

IV. Provider business mailing address

2560 N SHADELAND AVE STE A ATTN: ANN PATTERSON
INDIANAPOLIS IN
46219-1706
US

V. Phone/Fax

Practice location:
  • Phone: 478-765-4865
  • Fax:
Mailing address:
  • Phone: 317-275-8072
  • Fax: 317-275-8124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number11D0982593
License Number StateGA

VIII. Authorized Official

Name: MR. EDWARD M KRAMER
Title or Position: VP
Credential: M.D.
Phone: 317-275-8072