Provider Demographics
NPI:1104887330
Name:GWINNETT PATHOLOGY ASSOC PC
Entity type:Organization
Organization Name:GWINNETT PATHOLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELGADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-312-4524
Mailing Address - Street 1:PO BOX 1686
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1686
Mailing Address - Country:US
Mailing Address - Phone:706-232-0156
Mailing Address - Fax:
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:678-312-4524
Practice Address - Fax:770-682-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300030501Medicaid
GAGRP1831Medicare PIN
GAC12883Medicare PIN