Provider Demographics
NPI:1699753913
Name:ATLANTA DERMATOPATHOLOGY & PATHOLOGY ASSOCIATES
Entity type:Organization
Organization Name:ATLANTA DERMATOPATHOLOGY & PATHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-994-1360
Mailing Address - Street 1:1800 PHOENIX BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5593
Mailing Address - Country:US
Mailing Address - Phone:770-994-1360
Mailing Address - Fax:770-994-1264
Practice Address - Street 1:1800 PHOENIX BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-5593
Practice Address - Country:US
Practice Address - Phone:770-994-1360
Practice Address - Fax:770-994-1264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-018291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65000869LAMedicare ID - Type Unspecified