Provider Demographics
NPI:1366524563
Name:LABORATORY SOUTH INC
Entity type:Organization
Organization Name:LABORATORY SOUTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:SPRINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-270-9471
Mailing Address - Street 1:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0009
Mailing Address - Country:US
Mailing Address - Phone:770-270-9471
Mailing Address - Fax:770-270-9470
Practice Address - Street 1:189 W ATHENS ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2295
Practice Address - Country:US
Practice Address - Phone:770-270-9471
Practice Address - Fax:770-270-9470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044134291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA320731OtherWELLCARE ID NUMBER
GA10066591OtherAMERIGROUP ID NUMBER
GA389117OtherBCBS PROVIDER NUMBER
GA320731OtherWELLCARE ID NUMBER
GA10066591OtherAMERIGROUP ID NUMBER