MEDICARE: ACCESS DERMPATH, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1023684453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACCESS DERMPATH, INC.

Provider Business Mailing Address
First Line	:	3705 S HIGHWAY 27 STE 201
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-7950
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	72 KENT RD STE 7
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-1695
Country	:	US
Telephone Number	:	229-213-9066
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	VICKI TILTON
Credential	:
Telephone Number	:	352-241-6280

Provider Enumeration Date	:	05/27/2021
Last Update Date	:	05/27/2021

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