Provider Demographics
NPI:1558547273
Name:PATHOLOGY MEDICAL LABORATORIES PA
Entity Type:Organization
Organization Name:PATHOLOGY MEDICAL LABORATORIES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:RENDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-787-6733
Mailing Address - Street 1:913 E NORTH BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5364
Mailing Address - Country:US
Mailing Address - Phone:352-787-6733
Mailing Address - Fax:352-787-9228
Practice Address - Street 1:913 E NORTH BLVD STE B
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5364
Practice Address - Country:US
Practice Address - Phone:352-787-6733
Practice Address - Fax:352-787-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF83867Medicare UPIN
FLK2676Medicare PIN