Basic Information
| Provider Information | |||||||||
| NPI: | 1346222346 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW SMYRNA BEACH PATHOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 4076482065 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 PALMETTO ST | ||||||||
| Address2: | DEPT. OF PATHOLOGY | ||||||||
| City: | NEW SMYRNA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321687322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864273401 | ||||||||
| FaxNumber: | 3864246465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOTTING | ||||||||
| AuthorizedOfficialFirstName: | ARTHUR | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3864273401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | CH9314 | 01 | RAILROAD MEDICARE | OTHER |