MEDICARE: PATHOLOGY MEDICAL LABORATORIES 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	291U00000X	Clinical Medical Laboratory		FL

General Provider Information

NPI Number	:	1558547273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHOLOGY MEDICAL LABORATORIES PA

Provider Business Mailing Address
First Line	:	913 E NORTH BLVD STE B
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-5364
Country	:	US
Telephone Number	:	352-787-6733
Fax Number	:	352-787-9228

Provider Business Practice Location Address
First Line	:	913 E NORTH BLVD STE B
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-5364
Country	:	US
Telephone Number	:	352-787-6733
Fax Number	:	352-787-9228

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SUSAN MARY RENDON
Credential	:	M.D.
Telephone Number	:	352-787-6733

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	01/11/2008

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