Basic Information
| Provider Information | |||||||||
| NPI: | 1962485581 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEACOAST PATHOLOGY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11025 RCA CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616265512 | ||||||||
| FaxNumber: | 5616264530 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 ALUMNI DR | ||||||||
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| City: | EXETER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038332128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037788522 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | GRATTENDICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5616265512 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 406 | 01 | HEALTHSOURCE | OTHER | 202050900 | 01 | FED WORKERS COMP | OTHER | 9701478 | 05 | MA | MEDICAID | CB4418 | 01 | NH | RAILROAD MEDICARE | OTHER | 600310 | 01 | TUFTS | OTHER | 81223726 | 05 | NH | MEDICAID | 60510 | 01 | AETNA/USHEALTH | OTHER |