Healthcare Provider Details

I. General information

NPI: 1992769525
Provider Name (Legal Business Name): NEWBERRY PATHOLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 12/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2669 KINARD ST
NEWBERRY SC
29108-2911
US

IV. Provider business mailing address

PO BOX 49009
GREENWOOD SC
29649-0001
US

V. Phone/Fax

Practice location:
  • Phone: 888-446-9898
  • Fax: 803-276-5521
Mailing address:
  • Phone: 864-223-3070
  • Fax: 864-223-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number5559
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number5559
License Number StateSC

VIII. Authorized Official

Name: MRS. FRANCES S PUCKETT
Title or Position: PRESIDENT/FINANCIAL DIRECTOR
Credential:
Phone: 864-223-3070