=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699893412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH PATH, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 01/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1520 N LEG RD
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-4332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-722-1846
-----------------------------------------------------
Fax | 706-722-3323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1520 N LEG RD
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-4332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-722-1846
-----------------------------------------------------
Fax | 706-722-3323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEPHEN C MULLINS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 706-434-4121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZD0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology (Pathology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------