Healthcare Provider Details

I. General information

NPI: 1609825710
Provider Name (Legal Business Name): SOUTHEASTERN PATHOLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 27TH STREET
LUMBERTON NC
28359
US

IV. Provider business mailing address

PO BOX 847
LUMBERTON NC
28359
US

V. Phone/Fax

Practice location:
  • Phone: 910-671-5189
  • Fax: 910-671-5085
Mailing address:
  • Phone: 910-738-1921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number9300163
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNC

VIII. Authorized Official

Name: DR. RICHARD DEWITT JOHNSON
Title or Position: PRESIDENT SPA PA
Credential: MD
Phone: 910-671-5189