Provider Demographics
NPI:1477513323
Name:INDIAN RIVER PATHOLOGY LLC
Entity type:Organization
Organization Name:INDIAN RIVER PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANIL
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-466-6651
Mailing Address - Street 1:PO BOX 881016
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34988-1016
Mailing Address - Country:US
Mailing Address - Phone:772-466-6651
Mailing Address - Fax:772-466-0662
Practice Address - Street 1:6696 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-1423
Practice Address - Country:US
Practice Address - Phone:772-466-6651
Practice Address - Fax:772-466-0662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46694291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252482100Medicaid
FL41580OtherBLUECROSS
FL41580OtherBLUECROSS
FLK2931Medicare ID - Type Unspecified