Healthcare Provider Details

I. General information

NPI: 1538368501
Provider Name (Legal Business Name): OCMULGEE MEDICAL PATHOLOGY ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 MONTREAL CIR STE A-C
TUCKER GA
30084-6802
US

IV. Provider business mailing address

14275 MIDWAY RD SUITE 400
ADDISON TX
75001-3614
US

V. Phone/Fax

Practice location:
  • Phone: 678-406-1289
  • Fax: 770-621-7530
Mailing address:
  • Phone: 214-932-8029
  • Fax: 610-271-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number11D1066992
License Number StateGA

VIII. Authorized Official

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