Provider Demographics
NPI:1891236816
Name:PATH MEDICAL, LLC
Entity Type:Organization
Organization Name:PATH MEDICAL, LLC
Other - Org Name:PATH MEDICAL - SOUTH TAMPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MEDICAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNARDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:754-218-2164
Mailing Address - Street 1:2304 W OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1422
Mailing Address - Country:US
Mailing Address - Phone:754-218-2164
Mailing Address - Fax:
Practice Address - Street 1:1369 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4885
Practice Address - Country:US
Practice Address - Phone:813-982-3456
Practice Address - Fax:813-982-3457
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATH MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8643261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherPIP