Basic Information
| Provider Information | |||||||||
| NPI: | 1346286226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST COAST PATHOLOGY OF FLORIDA PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60100 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294190100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056654614 | ||||||||
| FaxNumber: | 7707765966 | ||||||||
| Practice Location | |||||||||
| Address1: | 11375 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346135409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056654614 | ||||||||
| FaxNumber: | 7707765966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 07/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOBLEY | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3525966632 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 77905A | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 058311101 | 05 | FL | MEDICAID | 77905 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 058311100 | 05 | FL | MEDICAID |