MEDICARE: INTEGRATED REGIONAL LABORATORIES PATHOLOGY SERVICES, LLC

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician

General Provider Information

NPI Number	:	1699531640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED REGIONAL LABORATORIES PATHOLOGY SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 741087
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-1087
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2560 S US HIGHWAY 17/92
Second Line	:
City	:	CASSELBERRY
State	:	FL
Zip	:	32707-2938
Country	:	US
Telephone Number	:	407-562-0959
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICE
Name	:	MICHAEL JAMAINE DAVIS
Credential	:
Telephone Number	:	561-402-4256

Provider Enumeration Date	:	02/27/2024
Last Update Date	:	02/27/2024

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