Basic Information
| Provider Information | |||||||||
| NPI: | 1487800256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHOALS PATHOLOGY ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7111 FAIRWAY DRIVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334184207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617126200 | ||||||||
| FaxNumber: | 5617127349 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 BEVERLY AVE | ||||||||
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| City: | MUSCLE SHOALS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356613255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563831160 | ||||||||
| FaxNumber: | 2563819755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6105503000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 01D0641610 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 09015149 | 05 | MS | MEDICAID | 529902810 | 05 | AL | MEDICAID |