Provider Demographics
NPI:1881899458
Name:OCONEE PATHOLOGY ASSOCIATES, P.C.
Entity type:Organization
Organization Name:OCONEE PATHOLOGY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:WENDALL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-454-3688
Mailing Address - Street 1:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31059-1705
Mailing Address - Country:US
Mailing Address - Phone:478-454-3688
Mailing Address - Fax:
Practice Address - Street 1:821 N COBB ST
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2343
Practice Address - Country:US
Practice Address - Phone:478-454-3688
Practice Address - Fax:478-454-3694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030927207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA297058OtherWELLCARE
GADD8654OtherRAILROAD MEDICARE
GA118365OtherPEACH STATE HLT PLANS
GA727301OtherBCBSGA PROVIDER #
GA10049818OtherAMERIGROUP
GA118365OtherPEACH STATE HLT PLANS