Provider Demographics
NPI:1043326861
Name:SOUTHEASTERN PATHOLOGY ASSOCIATES AT WAYNE MEMORIAL INC
Entity Type:Organization
Organization Name:SOUTHEASTERN PATHOLOGY ASSOCIATES AT WAYNE MEMORIAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:E
Authorized Official - Last Name:GODBEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-261-2669
Mailing Address - Street 1:PO BOX 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-0309
Mailing Address - Country:US
Mailing Address - Phone:843-554-9300
Mailing Address - Fax:843-566-8780
Practice Address - Street 1:865 S 1ST ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0210
Practice Address - Country:US
Practice Address - Phone:912-261-2669
Practice Address - Fax:912-261-0561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA04833OtherBSGA WAYNE
GA04833OtherBSGA WAYNE
GAGRP3303Medicare PIN