Basic Information
| Provider Information | |||||||||
| NPI: | 1558451666 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMPATH NEW ENGLAND, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11025 RCA CENTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6151458225 | ||||||||
| FaxNumber: | 8447519263 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 SOLDIERS FIELD RD STE 3800 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021351047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172547284 | ||||||||
| FaxNumber: | 6172544116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | GRATTENDICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5615145822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 3429 | MA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 22D1049111 | 01 | MA | CLIA | OTHER | 110074861A | 05 | MA | MEDICAID |