Basic Information
| Provider Information | |||||||||
| NPI: | 1467820662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GO | ||||||||
| FirstName: | MARK LOUIE | ||||||||
| MiddleName: | SEVILLA | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ASCP(CM) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1580 SAWGRASS CORPORATE PKWY | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543324445 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1580 SAWGRASS CORPORATE PKWY | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543324445 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2015 | ||||||||
| LastUpdateDate: | 09/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246QM0706X | Y | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Pathology | Medical Technologist |
No ID Information.