Provider Demographics
NPI:1265494702
Name:DRS CLACK SPENCER WHITE & MCCORMACK PA
Entity Type:Organization
Organization Name:DRS CLACK SPENCER WHITE & MCCORMACK PA
Other - Org Name:SARASOTA PATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-362-8900
Mailing Address - Street 1:2001 WEBBER ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-5237
Mailing Address - Country:US
Mailing Address - Phone:941-362-8900
Mailing Address - Fax:941-362-8987
Practice Address - Street 1:2001 WEBBER ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5237
Practice Address - Country:US
Practice Address - Phone:941-362-8900
Practice Address - Fax:941-362-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZC0500X, 207ZP0102X
FL800000813291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058166600Medicaid
FL209040OtherSTAYWELL
FL690005346OtherPALMETTO GBA
FLL8218OtherBCBS LAB
FL99676OtherBLUE SHIELD
FL99676OtherBLUE SHIELD