Basic Information
| Provider Information | |||||||||
| NPI: | 1306827712 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POMPTON PLAINS PATHOLOGISTS P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
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| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 4076482065 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 W PARKWAY | ||||||||
| Address2: | DEPT. OF PATHOLOGY | ||||||||
| City: | POMPTON PLAINS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074441647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738315046 | ||||||||
| FaxNumber: | 9738315194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 08/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | AHMED | ||||||||
| AuthorizedOfficialFirstName: | ESSAM | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9738315046 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 8605301 | 05 | NJ | MEDICAID | CH9514 | 01 | RAILROAD MEDICARE | OTHER |