Provider Demographics
NPI:1073841573
Name:MID SOUTH COMMUNITY PATHOLOGY
Entity type:Organization
Organization Name:MID SOUTH COMMUNITY PATHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-528-2836
Mailing Address - Street 1:1805 N JACKSON ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2290
Mailing Address - Country:US
Mailing Address - Phone:931-461-8871
Mailing Address - Fax:931-461-8874
Practice Address - Street 1:1805 N JACKSON ST
Practice Address - Street 2:SUITE 7
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2290
Practice Address - Country:US
Practice Address - Phone:931-461-8871
Practice Address - Fax:931-461-8874
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY PATHOLOGY LABORATORY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-23
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1965207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty