Provider Demographics
NPI:1912172024
Name:PALM BEACH PATHOLOGY PA
Entity Type:Organization
Organization Name:PALM BEACH PATHOLOGY PA
Other - Org Name:ST. MARYS PATHOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-240-9555
Mailing Address - Street 1:PO BOX 4117
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33402-4117
Mailing Address - Country:US
Mailing Address - Phone:954-240-9555
Mailing Address - Fax:770-666-9514
Practice Address - Street 1:901 45TH ST
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2413
Practice Address - Country:US
Practice Address - Phone:954-240-9555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL99070OtherBCBS
FL258264300Medicaid
FL99070OtherBCBS