Basic Information
| Provider Information | |||||||||
| NPI: | 1568403988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESTATEE PATHOLOGY ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5620 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 3949 S COBB DR SE | ||||||||
| Address2: | |||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300806342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704385215 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COCHRAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7704385215 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | DC3670 | 01 | RAILROAD MEDICARE | OTHER |