Basic Information
| Provider Information | |||||||||
| NPI: | 1336128164 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEVELAND SKIN PATHOLOGY LABORATORY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11025 RCA CENTER DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615145822 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3737 PARK EAST DRIVE | ||||||||
| Address2: | SUITE #202 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164647770 | ||||||||
| FaxNumber: | 2164647531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 09/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | VALLADARES | ||||||||
| AuthorizedOfficialFirstName: | DINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CREDENTIALING & PE | ||||||||
| AuthorizedOfficialTelephone: | 5615145822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | CLIA 36D0656050 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 36D0656050 | 01 | OH | CLIA | OTHER | 0252560 | 05 | OH | MEDICAID |