MEDICARE: CAROLYN D PASS PA

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	174400000X	Specialist	ME73921	FL

General Provider Information

NPI Number	:	1467621151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLYN D PASS PA

Provider Business Mailing Address
First Line	:	1105 DRUID CIR
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33853-4339
Country	:	US
Telephone Number	:	863-676-8237
Fax Number	:	863-676-8207

Provider Business Practice Location Address
First Line	:	1105 DRUID CIR
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33853-4339
Country	:	US
Telephone Number	:	863-676-8237
Fax Number	:	863-676-8207

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MS. CAROLYN D PASS
Credential	:	M.D.
Telephone Number	:	863-676-8237

Provider Enumeration Date	:	02/27/2008
Last Update Date	:	02/27/2008

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