MEDICARE: PATH MEDICAL, 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	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center
2	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HCC9731	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1801332697
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATH MEDICAL, LLC

Provider Business Mailing Address
First Line	:	2304 W OAKLAND PARK BLVD
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33311-1422
Country	:	US
Telephone Number	:	754-218-2164
Fax Number	:

Provider Business Practice Location Address
First Line	:	3117 W COLUMBUS DR STE 209
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-1855
Country	:	US
Telephone Number	:	407-367-5160
Fax Number	:	407-730-9928

Authorized Official
Title or Position	:	DIRECTOR OF MEDICAL SERVICES
Name	:	DR. NEIL BONNARDEL
Credential	:	MD
Telephone Number	:	754-218-2164

Provider Enumeration Date	:	01/17/2017
Last Update Date	:	11/06/2019

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