Provider Demographics
NPI:1649516386
Name:SOUTH EASTERN UTAH PATHOLOGY PLCC
Entity type:Organization
Organization Name:SOUTH EASTERN UTAH PATHOLOGY PLCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-637-8358
Mailing Address - Street 1:1588 N COAL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-7615
Mailing Address - Country:US
Mailing Address - Phone:435-637-8358
Mailing Address - Fax:
Practice Address - Street 1:1588 N COAL CREEK RD
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-7615
Practice Address - Country:US
Practice Address - Phone:435-637-8358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-28
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0105X
UT188453-1205207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty