Basic Information
| Provider Information | |||||||||
| NPI: | 1710146212 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEE DEE PATHOLOGY ASSOCIATES INC. | ||||||||
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| OtherOrganizationName: | PEE DEE PATHOLOGY ASSOCIATES PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30309 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294170309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435549300 | ||||||||
| FaxNumber: | 8435668780 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 PAMPLICO HWY | ||||||||
| Address2: | SUITE B210 | ||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295056064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436644314 | ||||||||
| FaxNumber: | 8436644340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 01/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | ROBEY | ||||||||
| AuthorizedOfficialFirstName: | DENNISON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8436644300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | SC | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 480214 | 05 | SC | MEDICAID |