Provider Demographics
NPI:1134189491
Name:ETOWAH PATHOLOGY ASSOCIATES LLC
Entity type:Organization
Organization Name:ETOWAH PATHOLOGY ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-382-1530
Mailing Address - Street 1:PO BOX 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-0309
Mailing Address - Country:US
Mailing Address - Phone:843-544-9300
Mailing Address - Fax:843-566-8780
Practice Address - Street 1:960 JOE FRANK HARRIS PKWY SE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2129
Practice Address - Country:US
Practice Address - Phone:770-382-1530
Practice Address - Fax:770-387-8198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034648207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherBCBS GROUP#
GA=========OtherBCBS
GAGRP3187Medicare PIN