Healthcare Provider Details

I. General information

NPI: 1669153011
Provider Name (Legal Business Name): INTEGRATED REGIONAL LABORATORIES PATHOLOGY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 07/28/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

IV. Provider business mailing address

PO BOX 741087
ATLANTA GA
30374-1087
US

V. Phone/Fax

Practice location:
  • Phone: 954-507-6780
  • Fax: 866-262-5507
Mailing address:
  • Phone: 954-507-6780
  • Fax: 866-262-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL J DAVIS
Title or Position: COO
Credential:
Phone: 561-402-4256