Healthcare Provider Details

I. General information

NPI: 1508848300
Provider Name (Legal Business Name): SOUTHEASTERN PATHOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W 8TH ST NE
ROME GA
30165-2723
US

IV. Provider business mailing address

311 W 8TH ST NE
ROME GA
30165-2723
US

V. Phone/Fax

Practice location:
  • Phone: 706-291-8702
  • Fax: 706-291-6514
Mailing address:
  • Phone: 706-291-8702
  • Fax: 706-291-6514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number11D0256839
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number11D0256839
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number11D0256839
License Number StateGA

VIII. Authorized Official

Name: TINA G BURKHALTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-314-0120