Basic Information
| Provider Information | |||||||||
| NPI: | 1932290913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERIPATH NEW YORK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DERMPATH DIAGNOSTICS NEW ENGLAND | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7111 FAIRWAY DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334184207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617126265 | ||||||||
| FaxNumber: | 5617127349 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 FORBES RD | ||||||||
| Address2: | SUITE 260E | ||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021842605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663709787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 09/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6105503000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0800228 | 05 | MA | MEDICAID | 22D2004456 | 01 | MA | CLIA | OTHER |