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General NPI Number Information
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NPI Number | 1750957072
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Entity Type | Organization
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Legal Business Name | INTEGRATED REGIONAL LABORATORIES PATHOLOGY SERVICES, LLC
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Dates
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Enumeration Date | 05/27/2021
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Last Update Date | 05/27/2021
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Provider Practice Location Address
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Address Line | 2626 CAPITAL MEDICAL BLVD
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City | TALLAHASSEE
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State | FL
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Zip | 32308-4402
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Country | US
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Telephone | 850-325-5888
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 741087
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City | ATLANTA
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State | GA
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Zip | 30374-1087
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/VP OF PPERATIONS
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Name | JOHN RODKEY
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Credential |
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Telephone | 850-523-2117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number |
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License Number State |
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Legacy Identifiers
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Identifier #1
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Identifier Code | 002225645
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Identifier Type | MEDICAID
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Identifier State | FL
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Identifier Issuer | Florida Medicaid Provider ID
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 002225645
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Identifier Type | MEDICAID
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Identifier State | FL
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Identifier Issuer | Florida Medicaid Provider ID
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