Provider Demographics
NPI:1508848300
Name:SOUTHEASTERN PATHOLOGY, P.C.
Entity Type:Organization
Organization Name:SOUTHEASTERN PATHOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURKHALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-314-0120
Mailing Address - Street 1:311 W 8TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-2723
Mailing Address - Country:US
Mailing Address - Phone:706-291-8702
Mailing Address - Fax:706-291-6514
Practice Address - Street 1:311 W 8TH ST NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2723
Practice Address - Country:US
Practice Address - Phone:706-291-8702
Practice Address - Fax:706-291-6514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D0256839207ZC0500X, 207ZD0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11-0291OtherUHC PRACTICE PROV#
GA11D0256839OtherCLIA#
GA00067691AMedicaid
=========OtherFEDERAL TIN #
GA11-0291OtherUHC PRACTICE PROV#
=========OtherFEDERAL TIN #
GA11D0256839OtherCLIA#