MEDICARE: INTEGRATED REGIONAL LABORATORIES PATHOLOGY SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518540087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED REGIONAL LABORATORIES PATHOLOGY SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 741087
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-1087
Country	:	US
Telephone Number	:	854-507-6780
Fax Number	:	866-262-5507

Provider Business Practice Location Address
First Line	:	12530 US HIGHWAY 301 S
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33578-7651
Country	:	US
Telephone Number	:	813-571-5193
Fax Number	:	813-571-5169

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	JOHN RODKEY
Credential	:
Telephone Number	:	850-523-2117

Provider Enumeration Date	:	05/03/2021
Last Update Date	:	05/03/2021

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