Provider Demographics
NPI:1609825710
Name:SOUTHEASTERN PATHOLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:SOUTHEASTERN PATHOLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SPA PA
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DEWITT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-671-5189
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359
Mailing Address - Country:US
Mailing Address - Phone:910-738-1921
Mailing Address - Fax:
Practice Address - Street 1:300 W 27TH STREET
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28359
Practice Address - Country:US
Practice Address - Phone:910-671-5189
Practice Address - Fax:910-671-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300163207ZP0102X
NC291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02710OtherBLUE CROSS BLUE SHIELD
NC8902710Medicaid
G35082Medicare UPIN
NC02710OtherBLUE CROSS BLUE SHIELD
2231727Medicare PIN