MEDICARE: UNIVERSITY PATHOLOGISTS, INC.

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	291U00000X	Clinical Medical Laboratory	121	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	067852	OTHER	PR	CRUZ AZUL PROVIDER #
2	800078	OTHER	PR	MMM PROVIDER NUMBER
3	81063	OTHER	PR	TRIPLE-S, INC. PROVIDER #
4	9140009	OTHER	PR	HUMANA PROVIDER NUMBER

General Provider Information

NPI Number	:	1871580605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY PATHOLOGISTS, INC.

Provider Business Mailing Address
First Line	:	COND MADRID 1760 LOIZA STREET
Second Line	:	SUITE #204
City	:	SAN JUAN
State	:	PR
Zip	:	00911-1801
Country	:	US
Telephone Number	:	787-726-5486
Fax Number	:	787-268-4417

Provider Business Practice Location Address
First Line	:	COND MADRID 1760 LOIZA STREET
Second Line	:	SUITE 204
City	:	SAN JUAN
State	:	PR
Zip	:	00911-1801
Country	:	US
Telephone Number	:	787-726-5486
Fax Number	:	787-268-4417

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MANUEL A MARCIAL
Credential	:	MD
Telephone Number	:	787-726-5484

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	04/27/2010

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