Provider Demographics
NPI:1194010058
Name:FLORIDA MEDICAL STAT LABORATORY
Entity Type:Organization
Organization Name:FLORIDA MEDICAL STAT LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:GERREN
Authorized Official - Suffix:
Authorized Official - Credentials:BA,MS
Authorized Official - Phone:954-933-2439
Mailing Address - Street 1:7660 N NOB HILL RD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-1843
Mailing Address - Country:US
Mailing Address - Phone:954-933-2439
Mailing Address - Fax:
Practice Address - Street 1:7660 N NOB HILL RD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-1843
Practice Address - Country:US
Practice Address - Phone:954-933-2439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
FLNOT ISSUED YET291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269842100OtherFILE NUMBER FOR AHCA