1447227590 NPI number — VIVID PATHOLOGY PA

Table of content: (NPI 1447227590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447227590 NPI number — VIVID PATHOLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIVID PATHOLOGY 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:
1447227590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4900 BAYOU BLVD STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32503-2533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-288-8325
Provider Business Mailing Address Fax Number:
843-664-4308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4900 BAYOU BLVD STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-2533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-288-8325
Provider Business Practice Location Address Fax Number:
850-416-6475
Provider Enumeration Date:
03/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FARMER
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
800-288-8325

Provider Taxonomy Codes

  • Taxonomy code: 207ZC0500X , with the licence number:  65194 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: ME53456 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00378 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 064208800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 529001600 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 064208800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".