1992963268 NPI number — SOUTHEASTERN PATHOLOGY ASSOCIATES PC

Table of content: (NPI 1992963268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992963268 NPI number — SOUTHEASTERN PATHOLOGY ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN PATHOLOGY ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992963268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 INDIGO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31525-6865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-261-2671
Provider Business Mailing Address Fax Number:
912-261-0561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 INDIGO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31525-6865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-261-2669
Provider Business Practice Location Address Fax Number:
912-261-0753
Provider Enumeration Date:
05/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GODBEY
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
912-261-2669

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 197742702B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 030707600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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