Provider Demographics
NPI:1184698086
Name:SURGICAL PATHOLOGY LABORATORIES PA
Entity type:Organization
Organization Name:SURGICAL PATHOLOGY LABORATORIES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BULSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-545-2339
Mailing Address - Street 1:8455 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-1206
Mailing Address - Country:US
Mailing Address - Phone:727-548-7732
Mailing Address - Fax:727-545-1644
Practice Address - Street 1:8455 66TH ST
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-1206
Practice Address - Country:US
Practice Address - Phone:727-545-2339
Practice Address - Fax:727-545-1644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800014408291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL220025650OtherRR MEDICARE
FL277272800Medicaid
FL80591OtherBCBS
FLL9274OtherBCBS
FL277272800Medicaid
FL80591AMedicare PIN