Southeastern Dermatopathology, LLC

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

47704 Issued in GA

Legal business name

SOUTHEASTERN DERMATOPATHOLOGY, LLC

Practice address

1067 Windermere Xing
Cumming, GA 30041-6104

Phone

(205) 910-6852

NPI assigned

Jul 19, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Molly Bouldin, M.D.

Title

Laboratory Director

Phone

(205) 910-6852

Specialties & licenses 1

Addresses

Other identifiers 3

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1311033600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1311033600000",
    "number": "1932497492",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1067 WINDERMERE XING",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300416104",
            "telephone_number": "205-910-6852"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1067 WINDERMERE XING",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300416104",
            "telephone_number": "205-910-6852"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEASTERN DERMATOPATHOLOGY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-07-19",
        "last_updated": "2011-07-19",
        "status": "A",
        "authorized_official_last_name": "BOULDIN",
        "authorized_official_first_name": "MOLLY",
        "authorized_official_title_or_position": "LABORATORY DIRECTOR",
        "authorized_official_telephone_number": "205-910-6852",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "GA",
            "license": "47704",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE FLORIDA",
            "identifier": "ME81020",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI TYPE 1",
            "identifier": "1174502827",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE GA",
            "identifier": "47704",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jozef Soltis, DMD
• Hyo Jin Song, MD
• Geetha Reddy Soodini, MD
• Barbara Ellen Vicar Sortor, PT
• Gabriel Sousa Lima
• Southern Medical Specialists, LLC
• Southern Smiles Dentistry Cumming PC (Sharon Springs Dental)
• Southern Surgical Assistants LLC
• Sovereign Rehabilitation of Cumming, LLC
• Laura J Sparks, P.T.

• Clinical Medical Laboratory in Cumming, GA
• Providers in Cumming, GA by specialty
• Clinical Medical Laboratory in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 19, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.