=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447227590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIVID PATHOLOGY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2006
-----------------------------------------------------
Last Update Date | 04/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4900 BAYOU BLVD STE 204
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-2533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-288-8325
-----------------------------------------------------
Fax | 850-416-6475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4900 BAYOU BLVD STE 204
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-2533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-288-8325
-----------------------------------------------------
Fax | 843-664-4308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHARLES FARMER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 800-288-8325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZC0500X
-----------------------------------------------------
Taxonomy Name | Cytopathology Physician
-----------------------------------------------------
License Number | 65194
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | ME53456
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------