Provider Demographics
NPI:1538368501
Name:OCMULGEE MEDICAL PATHOLOGY ASSOCIATION INC
Entity type:Organization
Organization Name:OCMULGEE MEDICAL PATHOLOGY ASSOCIATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-697-8378
Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:214-932-8029
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:1777 MONTREAL CIR STE A-C
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6802
Practice Address - Country:US
Practice Address - Phone:678-406-1289
Practice Address - Fax:770-621-7530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIPATH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-11
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D1066992291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
11D2230489OtherCLIA
SCL00269Medicaid
AL118944Medicaid
GA11D1066992OtherCLIA
AL118944Medicaid