Basic Information
| Provider Information | |||||||||
| NPI: | 1568637932 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALM BEACH PATHOLOGY PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARTIN PATHOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4117 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334024117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542409555 | ||||||||
| FaxNumber: | 7707765966 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349942338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542409555 | ||||||||
| FaxNumber: | 7707765966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 08/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOLTON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9542409555 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 77313 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 258264300 | 05 | FL | MEDICAID |