Provider Demographics
NPI:1487663860
Name:LABORATORY OF DERMATOPATHOLOGY ADX, LLC
Entity Type:Organization
Organization Name:LABORATORY OF DERMATOPATHOLOGY ADX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRATTENDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-514-5822
Mailing Address - Street 1:11025 RCA CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4269
Mailing Address - Country:US
Mailing Address - Phone:561-514-5822
Mailing Address - Fax:
Practice Address - Street 1:80 CROSSWAYS PARK DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2047
Practice Address - Country:US
Practice Address - Phone:516-944-3883
Practice Address - Fax:516-833-2936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPFI 3199207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLLC011Medicare PIN