MEDICARE: SOUTHEAST PATHOLOGY CONSULTANTS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1720546468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST PATHOLOGY CONSULTANTS, INC.

Provider Business Mailing Address
First Line	:	1815 BACK CREEK DR STE 100
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-2159
Country	:	US
Telephone Number	:	980-721-6622
Fax Number	:

Provider Business Practice Location Address
First Line	:	1815 BACK CREEK DR STE 100
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-2159
Country	:	US
Telephone Number	:	980-721-6622
Fax Number	:

Authorized Official
Title or Position	:	PATHOLOGIST
Name	:	OMAR IDLIBI
Credential	:	MC
Telephone Number	:	980-721-6622

Provider Enumeration Date	:	03/12/2019
Last Update Date	:	02/04/2020

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