Provider Demographics
NPI:1972010346
Name:PATH MEDICAL, LLC
Entity Type:Organization
Organization Name:PATH MEDICAL, LLC
Other - Org Name:PATH MEDICAL - NORTHSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:
Authorized Official - First Name:ANICIA
Authorized Official - Middle Name:O
Authorized Official - Last Name:VICENTE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:407-367-5166
Mailing Address - Street 1:6220 S ORANGE BLOSSOM TRL STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-4678
Mailing Address - Country:US
Mailing Address - Phone:407-367-5160
Mailing Address - Fax:407-730-9928
Practice Address - Street 1:9119 MERRILL RD STE 32
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-4306
Practice Address - Country:US
Practice Address - Phone:904-575-3695
Practice Address - Fax:855-831-2252
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATH MEDICAL CENTER HOLDINGS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC11220261QH0100X
FLHCC11222261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL475580767OtherPIP