Provider Demographics
NPI:1558802579
Name:PATH MEDICAL, LLC
Entity Type:Organization
Organization Name:PATH MEDICAL, LLC
Other - Org Name:PATH MEDICAL - CENTRAL TAMPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANICIA
Authorized Official - Middle Name:O
Authorized Official - Last Name:VICENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-399-9070
Mailing Address - Street 1:4700 N HABANA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7116
Mailing Address - Country:US
Mailing Address - Phone:813-549-1515
Mailing Address - Fax:813-549-1516
Practice Address - Street 1:4700 N HABANA AVE STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7116
Practice Address - Country:US
Practice Address - Phone:813-549-1515
Practice Address - Fax:813-549-1516
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATH MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8645261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL475580767OtherPIP