Provider Demographics
NPI:1467621151
Name:CAROLYN D PASS PA
Entity Type:Organization
Organization Name:CAROLYN D PASS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-676-8237
Mailing Address - Street 1:1105 DRUID CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4339
Mailing Address - Country:US
Mailing Address - Phone:863-676-8237
Mailing Address - Fax:863-676-8207
Practice Address - Street 1:1105 DRUID CIR
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4339
Practice Address - Country:US
Practice Address - Phone:863-676-8237
Practice Address - Fax:863-676-8207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73921174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG39525Medicare UPIN
FL41992AMedicare PIN