Provider Demographics
NPI:1588681555
Name:PATHOLOGY GROUP PA
Entity Type:Organization
Organization Name:PATHOLOGY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MORELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-665-4614
Mailing Address - Street 1:5901 SW 74TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5165
Mailing Address - Country:US
Mailing Address - Phone:305-665-4614
Mailing Address - Fax:
Practice Address - Street 1:1717 N E ST
Practice Address - Street 2:SUITE 227
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6339
Practice Address - Country:US
Practice Address - Phone:305-665-4614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056546600Medicaid
FL056546600Medicaid
FL00047Medicare Oscar/Certification