1457897241 NPI number — PATH MEDICAL, LLC

Table of content: (NPI 1457897241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457897241 NPI number — PATH MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATH MEDICAL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PATH MEDICAL - CUTLER BAY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457897241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2304 W OAKLAND PARK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33311-1422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
754-218-2164
Provider Business Mailing Address Fax Number:
407-730-9928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11285 SW 211TH ST STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33189-2213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-960-2345
Provider Business Practice Location Address Fax Number:
386-960-2350
Provider Enumeration Date:
01/17/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BONNARDALE
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF MEDICAL SERVICES
Authorized Official Telephone Number:
754-218-2164

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  HCC8638 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)