Basic Information
| Provider Information | |||||||||
| NPI: | 1750550232 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPACE COAST PATHOLOGISTS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 4076482065 | ||||||||
| Practice Location | |||||||||
| Address1: | 13695 US HIGHWAY 1 | ||||||||
| Address2: | |||||||||
| City: | SEBASTIAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329583230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725893186 | ||||||||
| FaxNumber: | 7725891022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMEDBERG | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3219534804 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPACE COAST PATHOLOGISTS PA | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | C15028 | 01 | RAILROAD MEDICARE | OTHER |