Provider Demographics
NPI:1720546468
Name:SOUTHEAST PATHOLOGY CONSULTANTS, INC.
Entity Type:Organization
Organization Name:SOUTHEAST PATHOLOGY CONSULTANTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:IDLIBI
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:980-721-6622
Mailing Address - Street 1:1815 BACK CREEK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-2159
Mailing Address - Country:US
Mailing Address - Phone:980-721-6622
Mailing Address - Fax:
Practice Address - Street 1:1815 BACK CREEK DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-2159
Practice Address - Country:US
Practice Address - Phone:980-721-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Single Specialty
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical PathologyGroup - Single Specialty