1427019108 NPI number — TAMARAC PATHOLOGY GROUP PA

Table of content: (NPI 1427019108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427019108 NPI number — TAMARAC PATHOLOGY GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAMARAC PATHOLOGY GROUP PA
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:
1427019108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2030
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMOSASSA SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34447-2030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-621-3100
Provider Business Mailing Address Fax Number:
352-621-3121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6201 N SUNCOAST BLVD
Provider Second Line Business Practice Location Address:
DEPARTMENT OF PATHOLOGY
Provider Business Practice Location Address City Name:
CRYSTAL RIVER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34428-6712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-795-8372
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ESCLOPIS
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-795-8372

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: 272974100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 94803 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DE4684 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".