Provider Demographics
NPI:1699893412
Name:SOUTH PATH, P.C.
Entity type:Organization
Organization Name:SOUTH PATH, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-434-4121
Mailing Address - Street 1:1520 N LEG RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4332
Mailing Address - Country:US
Mailing Address - Phone:706-722-1846
Mailing Address - Fax:706-722-3323
Practice Address - Street 1:1520 N LEG RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4332
Practice Address - Country:US
Practice Address - Phone:706-722-1846
Practice Address - Fax:706-722-3323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZD0900X
GA207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA686556795AMedicaid
SCGPA941Medicaid
SCGPA941Medicaid
GAP00469881Medicare PIN