Basic Information
| Provider Information | |||||||||
| NPI: | 1104903723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERIDIAN LABORATORY PHYSICIANS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60280 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294190280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435698500 | ||||||||
| FaxNumber: | 8435698503 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 JACK MARTIN BLVD | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087247732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325281142 | ||||||||
| FaxNumber: | 7329201935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | RANGWALA | ||||||||
| AuthorizedOfficialFirstName: | ANIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7325281142 | ||||||||
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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 | 207ZP0102X | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 8093504 | 05 | NJ | MEDICAID |