Provider Demographics
NPI:1548224256
Name:SOUTHEASTERN CLINICAL LABORATORIES PA
Entity Type:Organization
Organization Name:SOUTHEASTERN CLINICAL LABORATORIES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-282-4245
Mailing Address - Street 1:PO BOX 52990
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-0048
Mailing Address - Country:US
Mailing Address - Phone:864-223-3600
Mailing Address - Fax:864-223-6054
Practice Address - Street 1:2003 FALLS RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-9700
Practice Address - Country:US
Practice Address - Phone:706-282-4245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4472207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA6065Medicaid
SCCL0838Medicare PIN
SCPA6065Medicaid