Basic Information
| Provider Information | |||||||||
| NPI: | 1134884851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED REGIONAL LABORATORIES PATHOLOGY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 741087 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303741087 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3476 S UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544754400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2021 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | JAMAINE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5614024256 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.