Basic Information
| Provider Information | |||||||||
| NPI: | 1679731095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | LI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30309 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435549300 | ||||||||
| FaxNumber: | 8435668780 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 INDIGO DRIVE | ||||||||
| Address2: | SOUTHEASTERN PATHOLOGY ASSOCIATES, INC. | ||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122791900 | ||||||||
| FaxNumber: | 9122610753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2008 | ||||||||
| LastUpdateDate: | 12/10/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 060276 | GA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZC0500X | 060276 | GA | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZD0900X | 060276 | GA | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZC0006X | 060276 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | 207ZP0102X | 0431544 | KS | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | MD.023759 | LA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZC0006X | 60276 | GA | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | 207ZP0102X | 103627 | NC | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | MD433014 | PA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 630468641 | 05 | GA | MEDICAID | 630468641H | 05 | GA | MEDICAID | 630468641F | 05 | GA | MEDICAID | 630468641G | 05 | GA | MEDICAID | 630468641C | 05 | GA | MEDICAID | 630468641E | 05 | GA | MEDICAID | 630468641I | 05 | GA | MEDICAID | 630468641J | 05 | GA | MEDICAID | 630468641A | 05 | GA | MEDICAID | 630468641B | 05 | GA | MEDICAID | 630468641D | 05 | GA | MEDICAID |