Basic Information
| Provider Information | |||||||||
| NPI: | 1912290248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANATEE PATHOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 SAN REMO AVE | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331463043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056662427 | ||||||||
| FaxNumber: | 3056661065 | ||||||||
| Practice Location | |||||||||
| Address1: | 8330 LAKEWOOD RANCH BLVD | ||||||||
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| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342025174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056662427 | ||||||||
| FaxNumber: | 3056661065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2011 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | FARRELL | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3056654614 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME31656 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 273956901 | 05 | FL | MEDICAID |