Basic Information
| Provider Information | |||||||||
| NPI: | 1467429407 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HALLMARK PATHOLOGY, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11025 RCA CENTER DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616265512 | ||||||||
| FaxNumber: | 5616264530 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | MELROSE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021763225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819793135 | ||||||||
| FaxNumber: | 7706669305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 09/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | GRATTENDICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 5616265512 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 22D0077627 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 9783156 | 05 | MA | MEDICAID | M20510 | 01 | MA | PTAM | OTHER |