Basic Information
| Provider Information | |||||||||
| NPI: | 1609825710 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN PATHOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847 | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107381921 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 W 27TH STREET | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715189 | ||||||||
| FaxNumber: | 9106715085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 09/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | DEWITT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT SPA PA | ||||||||
| AuthorizedOfficialTelephone: | 9106715189 | ||||||||
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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 | 291U00000X | NC | N | Laboratories | Clinical Medical Laboratory | 207ZP0102X | 9300163 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 02710 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 8902710 | 05 | NC | MEDICAID |