Basic Information
Provider Information | |||||||||
NPI: | 1801985601 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRADENTON PATHOLOGY PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5901 SW 74TH ST | ||||||||
Address2: | SUITE 202 | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331435165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056654614 | ||||||||
FaxNumber: | 3056670239 | ||||||||
Practice Location | |||||||||
Address1: | 2020 59TH ST W | ||||||||
Address2: |   | ||||||||
City: | BRADENTON | ||||||||
State: | FL | ||||||||
PostalCode: | 342094604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056654614 | ||||||||
FaxNumber: | 3056670239 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2006 | ||||||||
LastUpdateDate: | 01/16/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SENTENEY | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3056654614 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
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 | 260821900 | 05 | FL |   | MEDICAID |