Provider Demographics
NPI:1285372490
Name:PROTEAN PATHOLOGY SERVICES LLC
Entity type:Organization
Organization Name:PROTEAN PATHOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGLIOCCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-817-2042
Mailing Address - Street 1:6555 SANGER RD STE 260
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7686
Mailing Address - Country:US
Mailing Address - Phone:754-242-9682
Mailing Address - Fax:813-694-7006
Practice Address - Street 1:6555 SANGER RD STE 260
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7686
Practice Address - Country:US
Practice Address - Phone:754-242-9682
Practice Address - Fax:813-694-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
O4QJTOtherFLORIDA BLUE