1265006415 NPI number — ACCURATE PATHOLOGY SERVICES MD PL

Table of content: (NPI 1265006415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265006415 NPI number — ACCURATE PATHOLOGY SERVICES MD PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACCURATE PATHOLOGY SERVICES MD PL
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:
Provider Other Organization Name Type Code:
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:
1265006415
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742515
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17430 BALI BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER GARDEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34787-9507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-419-2496
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LOMBA
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
LUIS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
941-766-4120

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008708804 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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