Provider Demographics
NPI:1689652216
Name:BIOPSY DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:BIOPSY DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING AND PE
Authorized Official - Prefix:
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLADARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-514-5822
Mailing Address - Street 1:11025 RCA CENTER DRIVE
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:561-626-5512
Mailing Address - Fax:561-626-4530
Practice Address - Street 1:122 RIVERWALK BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936
Practice Address - Country:US
Practice Address - Phone:843-379-2939
Practice Address - Fax:843-379-2949
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AURORA DIAGNOSTICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-04
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0102X
SC14814291U00000X
GA052853291U00000X
AL00024917291U00000X
NC33767291U00000X
NYPFI8422291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ332430001Medicare PIN