Provider Demographics
NPI:1760689871
Name:PALM BEACH PATHOLOGY PA
Entity Type:Organization
Organization Name:PALM BEACH PATHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-659-0770
Mailing Address - Street 1:PO BOX 4117
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33402-4117
Mailing Address - Country:US
Mailing Address - Phone:561-659-0770
Mailing Address - Fax:770-776-5966
Practice Address - Street 1:2013 PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-6019
Practice Address - Country:US
Practice Address - Phone:561-659-0770
Practice Address - Fax:770-776-5966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258264300Medicaid
FLL8267OtherBCBS
FLL8267Medicare ID - Type Unspecified