Provider Demographics
NPI:1760669279
Name:JACK A ROSS
Entity Type:Organization
Organization Name:JACK A ROSS
Other - Org Name:PATHOLOGY SERVICES INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HILEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-505-2069
Mailing Address - Street 1:PO BOX 560977
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-0977
Mailing Address - Country:US
Mailing Address - Phone:321-639-2404
Mailing Address - Fax:321-635-7979
Practice Address - Street 1:770 CIDCO RD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-5814
Practice Address - Country:US
Practice Address - Phone:321-636-7766
Practice Address - Fax:321-636-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800022292291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory