Provider Demographics
NPI:1114153269
Name:THE PATHOLOGY GROUP OF NORTHWEST FLORIDA PLLC
Entity Type:Organization
Organization Name:THE PATHOLOGY GROUP OF NORTHWEST FLORIDA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NORTH
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-438-1154
Mailing Address - Street 1:PO BOX 3093
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-0993
Mailing Address - Country:US
Mailing Address - Phone:850-438-1154
Mailing Address - Fax:850-433-6034
Practice Address - Street 1:4724 N DAVIS HWY FL 2
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2339
Practice Address - Country:US
Practice Address - Phone:850-438-1154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00047OtherBCBS OF FL
FL001366802Medicaid
FL00047AOtherBCBS OF FL
FL001366801Medicaid
FL00047COtherBCBS OF FL
FL001366800Medicaid
FL=========OtherCHAMPUS/TRICARE
FL00047OtherBCBS OF FL
FL00047COtherBCBS OF FL