Healthcare Provider Details

I. General information

NPI: 1780656363
Provider Name (Legal Business Name): PROVIDENCE PATHOLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 FOREST DR C/O PROVIDENCE HOSPITAL
COLUMBIA SC
29204-2026
US

IV. Provider business mailing address

PO BOX 30309
CHARLESTON SC
29417-0309
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-5335
  • Fax: 803-256-5454
Mailing address:
  • Phone: 843-554-9300
  • Fax: 843-556-8780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number19654
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number19654
License Number StateSC

VIII. Authorized Official

Name: DR. JOSEPH ROBERT MODZELEWSKI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 803-256-5335