Basic Information
| Provider Information | |||||||||
| NPI: | 1619951621 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALM BEACH PATHOLOGY PA | ||||||||
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| OtherOrganizationName: | ST MARYS PATHOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 BUTLER STREET | ||||||||
| Address2: | PALM BEACH PATHOLOGY PA | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334076006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616590770 | ||||||||
| FaxNumber: | 5618023504 | ||||||||
| Practice Location | |||||||||
| Address1: | 2013 PONCE DELEON AVE | ||||||||
| Address2: | PALM BEACH PATHOLOGY PA | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334076019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616590770 | ||||||||
| FaxNumber: | 5618023504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | ABIS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5616590770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 258264300 | 05 | FL | MEDICAID |