Healthcare Provider Details

I. General information

NPI: 1225293707
Provider Name (Legal Business Name): VIVID PATHOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 N 9TH AVE
PENSACOLA FL
32504-8721
US

IV. Provider business mailing address

5149 N 9TH AVE STE 122
PENSACOLA FL
32504-8779
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-6894
  • Fax: 850-416-5487
Mailing address:
  • Phone: 850-416-2469
  • Fax: 843-664-4308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. CHARLES E FARMER
Title or Position: PRESIDENT
Credential: MD
Phone: 850-416-6894