Organization
SOUTHEASTERN DERMATOPATHOLOGY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MOLLY BOULDIN M.D. (LABORATORY DIRECTOR)
(205) 910-6852
Entity
Organization
Contact information
Practice address
1067 WINDERMERE XING, CUMMING, GA 30041-6104
(205) 910-6852
Mailing address
1067 WINDERMERE XING, CUMMING, GA 30041-6104
(205) 910-6852
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
47704
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1174502827
NPI TYPE 1
—
01
—
47704
MEDICAL LICENSE GA
—
01
—
ME81020
MEDICAL LICENSE FLORIDA
—
Enumeration date
07/19/2011
Last updated
07/19/2011
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