1558802579 NPI number — PATH MEDICAL, LLC

Table of content: (NPI 1558802579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558802579 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:
Provider Other Organization Name Type Code:
6
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:
1558802579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 N HABANA AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33614-7116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-549-1515
Provider Business Mailing Address Fax Number:
813-549-1516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 N HABANA AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33614-7116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-549-1515
Provider Business Practice Location Address Fax Number:
813-549-1516
Provider Enumeration Date:
03/09/2017

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  HCC8645 , 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 "PIP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com