Basic Information
| Provider Information | |||||||||
| NPI: | 1194018770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF PATHOLOGY, IMMUNOLOGY AND LABORATORY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1329 SW 16TH ST | ||||||||
| Address2: | ROOM 4230 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081128 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1329 SW 16TH ST | ||||||||
| Address2: | ROOM 4230 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650680 | ||||||||
| FaxNumber: | 3522657978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2011 | ||||||||
| LastUpdateDate: | 05/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | MAHLA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOCIATE DEAN OF GM | ||||||||
| AuthorizedOfficialTelephone: | 3522738909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 282N00000X | N | Hospitals | General Acute Care Hospital | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.