Healthcare Provider Details

I. General information

NPI: 1962371450
Provider Name (Legal Business Name): PATHOLOGIC DIAGNOSTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 RIBAUT ROAD
BEAUFORT SC
29902
US

IV. Provider business mailing address

219 W BRYAN ST STE 200
SAVANNAH GA
31401-2542
US

V. Phone/Fax

Practice location:
  • Phone: 843-783-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: PRISCILLA JONES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 912-925-0067