=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619940517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERIPATH FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2006
-----------------------------------------------------
Last Update Date | 11/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4225 E FOWLER AVE STE B
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33617-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-972-7100
-----------------------------------------------------
Fax | 813-972-8269
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14275 MIDWAY RD SUITE 400
-----------------------------------------------------
City | ADDISON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75001-3614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 610-271-4245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | KRISTIE M DOLAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 866-697-8378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 10D0275299
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------