Basic Information
| Provider Information | |||||||||
| NPI: | 1487601233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNCOAST PATHOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 446 TAMIAMI TRL S | ||||||||
| Address2: | SECOND FLOOR | ||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342852625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414833319 | ||||||||
| FaxNumber: | 9414833406 | ||||||||
| Practice Location | |||||||||
| Address1: | 446 TAMIAMI TRL S | ||||||||
| Address2: | SECOND FLOOR | ||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342852625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414833319 | ||||||||
| FaxNumber: | 9414833406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 08/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROTH | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9414833319 | ||||||||
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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 | 207ZC0500X | 800000658 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZD0900X | 800000658 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZI0100X | 800000658 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Immunopathology | 207ZP0105X | 800000658 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0102X | 800000658 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 002870300 | 05 | FL | MEDICAID |