1922500545 NPI number — PATH MEDICAL, LLC

Table of content: (NPI 1922500545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922500545 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 -MRI BOCA
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:
1922500545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6220 S ORANGE BLOSSOM TRL STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32809-4678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-399-9070
Provider Business Mailing Address Fax Number:
407-730-9928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 N MILITARY TRL STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33431-6347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-988-7868
Provider Business Practice Location Address Fax Number:
561-988-7873
Provider Enumeration Date:
02/28/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VICENTE
Authorized Official First Name:
ANICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING DIRECTOR
Authorized Official Telephone Number:
407-399-9070

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  HCC11175 , 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)

  • Identifier: 475580767 . This is a "475580767" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".