Provider Demographics
NPI:1750550232
Name:SPACE COAST PATHOLOGISTS PA
Entity type:Organization
Organization Name:SPACE COAST PATHOLOGISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:T
Authorized Official - Last Name:SMEDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-953-4804
Mailing Address - Street 1:PO BOX 144333
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-4333
Mailing Address - Country:US
Mailing Address - Phone:407-422-9831
Mailing Address - Fax:407-648-2065
Practice Address - Street 1:13695 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3230
Practice Address - Country:US
Practice Address - Phone:772-589-3186
Practice Address - Fax:772-589-1022
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPACE COAST PATHOLOGISTS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C15028OtherRAILROAD MEDICARE
FL77387AMedicare PIN