Provider Demographics
NPI:1104893353
Name:ATLANTA PATHOLOGY PA
Entity type:Organization
Organization Name:ATLANTA PATHOLOGY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF THE LAB
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BONDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-522-0414
Mailing Address - Street 1:315 BOULEVARD ST
Mailing Address - Street 2:#240
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312
Mailing Address - Country:US
Mailing Address - Phone:404-522-0414
Mailing Address - Fax:404-521-9254
Practice Address - Street 1:315 BOULEVARD NE
Practice Address - Street 2:SUITE 240
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1200
Practice Address - Country:US
Practice Address - Phone:404-522-0414
Practice Address - Fax:404-521-9254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300019824CMedicaid
GA300019824CMedicaid