1750550232 NPI number — SPACE COAST PATHOLOGISTS PA

Table of content: (NPI 1750550232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750550232 NPI number — SPACE COAST PATHOLOGISTS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPACE COAST PATHOLOGISTS 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:
1750550232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 144333
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:
32814-4333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-422-9831
Provider Business Mailing Address Fax Number:
407-648-2065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13695 US HIGHWAY 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBASTIAN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32958-3230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-589-3186
Provider Business Practice Location Address Fax Number:
772-589-1022
Provider Enumeration Date:
02/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SMEDBERG
Authorized Official First Name:
CARL
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
321-953-4804

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: C15028 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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