Healthcare Provider Details

I. General information

NPI: 1821104704
Provider Name (Legal Business Name): SOUTHEASTERN PATHOLOGY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 INDIGO DR
BRUNSWICK GA
31525-6865
US

IV. Provider business mailing address

203 INDIGO DR
BRUNSWICK GA
31525-6865
US

V. Phone/Fax

Practice location:
  • Phone: 912-261-2669
  • Fax: 912-261-0753
Mailing address:
  • Phone: 912-261-2669
  • Fax: 912-261-0561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number063012
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number800015943
License Number StateFL

VIII. Authorized Official

Name: DR. PATRICK E GODBEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 912-261-2669