Provider Demographics
NPI:1053530402
Name:ON-SITE PATHOLOGY LLC
Entity type:Organization
Organization Name:ON-SITE PATHOLOGY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-989-0027
Mailing Address - Street 1:951 BROKEN SOUND PKWY NW
Mailing Address - Street 2:STE 115
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-3507
Mailing Address - Country:US
Mailing Address - Phone:561-989-0027
Mailing Address - Fax:
Practice Address - Street 1:951 BROKEN SOUND PKWY NW
Practice Address - Street 2:STE 115
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-3507
Practice Address - Country:US
Practice Address - Phone:561-989-0027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800020612291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE9174Medicare ID - Type Unspecified