Basic Information
| Provider Information | |||||||||
| NPI: | 1972898435 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERIPATH FLORIDA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 BAYOU BLVD. | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504786626 | ||||||||
| FaxNumber: | 8504787016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2011 | ||||||||
| LastUpdateDate: | 11/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6105503000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 004078400 | 05 | FL | MEDICAID |