Provider Demographics
NPI:1295879278
Name:DERMPATH LAB LLC
Entity type:Organization
Organization Name:DERMPATH LAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:SELWYN
Authorized Official - Last Name:GLAUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-706-4843
Mailing Address - Street 1:1599 NW 9TH AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-1310
Mailing Address - Country:US
Mailing Address - Phone:561-393-8578
Mailing Address - Fax:561-393-8574
Practice Address - Street 1:1599 NW 9TH AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1310
Practice Address - Country:US
Practice Address - Phone:561-393-8578
Practice Address - Fax:561-393-8574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory