Healthcare Provider Details

I. General information

NPI: 1760428247
Provider Name (Legal Business Name): OCMULGEE MEDICAL PATHOLOGY ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 NORTHWEST PKWY SE SUITE 140
MARIETTA GA
30067-9321
US

IV. Provider business mailing address

14275 MIDWAY RD STE 400
ADDISON TX
75001-3614
US

V. Phone/Fax

Practice location:
  • Phone: 770-951-1793
  • Fax: 770-613-3380
Mailing address:
  • Phone: 866-836-7136
  • Fax: 610-271-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number11D1004139
License Number StateGA

VIII. Authorized Official

Name: KRISTIE M DOLAN
Title or Position: VICE PRESIDENT
Credential:
Phone: 866-697-8378