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	:	1750956108
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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3275 SW DARWIN BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-3317
Country	:	US
Telephone Number	:	772-807-6303
Fax Number	:

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

Provider Enumeration Date	:	05/26/2021
Last Update Date	:	05/26/2021

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