Provider Demographics
NPI:1851554455
Name:I MD PATHLAB LLC
Entity Type:Organization
Organization Name:I MD PATHLAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CR
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:MORALES-DUCRET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-236-1711
Mailing Address - Street 1:1500 N DIXIE HIGHWAY
Mailing Address - Street 2:SUITE 308
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-2717
Mailing Address - Country:US
Mailing Address - Phone:561-236-1711
Mailing Address - Fax:561-736-9807
Practice Address - Street 1:1500 N DIXIE HIGHWAY
Practice Address - Street 2:SUITE 308
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2717
Practice Address - Country:US
Practice Address - Phone:561-236-1711
Practice Address - Fax:561-736-9807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069744207ZD0900X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBC637Medicare PIN