Provider Demographics
NPI:1679731095
Name:MA, LI (MD)
Entity Type:Individual
Prefix:
First Name:LI
Middle Name:
Last Name:MA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417
Mailing Address - Country:US
Mailing Address - Phone:843-554-9300
Mailing Address - Fax:843-566-8780
Practice Address - Street 1:203 INDIGO DRIVE
Practice Address - Street 2:SOUTHEASTERN PATHOLOGY ASSOCIATES, INC.
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525
Practice Address - Country:US
Practice Address - Phone:912-279-1900
Practice Address - Fax:912-261-0753
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060276207ZP0102X, 207ZC0500X, 207ZD0900X, 207ZC0006X
KS0431544207ZP0102X
LAMD.023759207ZP0102X
GA60276207ZC0006X
NC103627207ZP0102X
PAMD433014207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA630468641Medicaid
GA630468641HMedicaid
GA630468641FMedicaid
GA630468641GMedicaid
GA630468641CMedicaid
GA630468641EMedicaid
GA630468641IMedicaid
GA630468641JMedicaid
GA630468641AMedicaid
GA630468641BMedicaid
GA630468641DMedicaid
GA630468641AMedicaid
GA630468641Medicaid
GA511I220053Medicare PIN