Provider Demographics
NPI:1447227590
Name:VIVID PATHOLOGY PA
Entity Type:Organization
Organization Name:VIVID PATHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-288-8325
Mailing Address - Street 1:4900 BAYOU BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2533
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:843-664-4308
Practice Address - Street 1:4900 BAYOU BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2533
Practice Address - Country:US
Practice Address - Phone:800-288-8325
Practice Address - Fax:850-416-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL65194207ZC0500X
FLME53456207ZP0102X
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00378OtherBCBS
FL064208800Medicaid
AL529001600Medicaid
FLE9047Medicare PIN
AL529001600Medicaid