Provider Demographics
NPI:1821104704
Name:SOUTHEASTERN PATHOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:SOUTHEASTERN PATHOLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:E
Authorized Official - Last Name:GODBEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-261-2669
Mailing Address - Street 1:203 INDIGO DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-6865
Mailing Address - Country:US
Mailing Address - Phone:912-261-2669
Mailing Address - Fax:912-261-0561
Practice Address - Street 1:203 INDIGO DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-6865
Practice Address - Country:US
Practice Address - Phone:912-261-2669
Practice Address - Fax:912-261-0753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0102X
GA063012291U00000X
FL800015943291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030707600Medicaid
GA197742702BMedicaid
FL031806000Medicaid
GA04485OtherBSGA GROUP
GA197742702AMedicaid
FL030703300Medicaid
FL38374OtherBSFL GROUP
FL031806000Medicaid
GA197742702BMedicaid
FL38374OtherBSFL GROUP
GAGRP3013Medicare PIN