Basic Information
| Provider Information | |||||||||
| NPI: | 1487663860 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LABORATORY OF DERMATOPATHOLOGY ADX, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11025 RCA CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615145822 | ||||||||
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| Practice Location | |||||||||
| Address1: | 80 CROSSWAYS PARK DRIVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WOODBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117972047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169443883 | ||||||||
| FaxNumber: | 5168332936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | GRATTENDICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5615145822 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | PFI 3199 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
No ID Information.