Basic Information
| Provider Information | |||||||||
| NPI: | 1992963268 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN PATHOLOGY ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 INDIGO DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315256865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882612671 | ||||||||
| FaxNumber: | 9122610561 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 INDIGO DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315256865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122612669 | ||||||||
| FaxNumber: | 9122610753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 11/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | GODBEY | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9122612669 | ||||||||
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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 | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 197742702B | 05 | GA | MEDICAID |