Basic Information
| Provider Information | |||||||||
| NPI: | 1619940517 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERIPATH FLORIDA LLC | ||||||||
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| OtherOrganizationName: | AMERIPATH CENTRAL FLORIDA (ACF) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 2423 SAND LAKE RD STE A | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328097641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003957284 | ||||||||
| FaxNumber: | 4078562312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOLAN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8666978378 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
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| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 10D0275299 | FL | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 200008140A | 05 | OK | MEDICAID | 2375960 | 05 | OH | MEDICAID | 37000106 | 05 | KY | MEDICAID | 88530850 | 05 | CO | MEDICAID | 149554709 | 05 | AR | MEDICAID | 030579102 | 05 | FL | MEDICAID | 4393873 | 05 | MI | MEDICAID | 830093 | 05 | AZ | MEDICAID | 7001213 | 05 | NC | MEDICAID | L00206 | 05 | SC | MEDICAID |