Provider Demographics
NPI:1316180300
Name:CAROLYN D. PASS, M.D., P.A.
Entity Type:Organization
Organization Name:CAROLYN D. PASS, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/CONTRACTING
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:P
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-294-5505
Mailing Address - Street 1:1255 STATE ROAD 60 E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4310
Mailing Address - Country:US
Mailing Address - Phone:863-676-8237
Mailing Address - Fax:863-676-8207
Practice Address - Street 1:320 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4113
Practice Address - Country:US
Practice Address - Phone:863-294-5505
Practice Address - Fax:863-299-5660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73921174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG39525Medicare UPIN
FL41992AMedicare PIN