Provider Demographics
NPI:1609039361
Name:ROBERTA M KILLEEN MD PA
Entity Type:Organization
Organization Name:ROBERTA M KILLEEN MD PA
Other - Org Name:SUNCOAST PATHOLOGY LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KILLEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-939-1584
Mailing Address - Street 1:2520 US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-3846
Mailing Address - Country:US
Mailing Address - Phone:727-939-1584
Mailing Address - Fax:
Practice Address - Street 1:2520 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34691-3846
Practice Address - Country:US
Practice Address - Phone:727-939-1584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800009658291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory