Basic Information
| Provider Information | |||||||||
| NPI: | 1336545508 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROMED PATHOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P. O. BOX 743 | ||||||||
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| City: | HACKETTSTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078400743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9089790200 | ||||||||
| FaxNumber: | 9089799934 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 WESCOTT DRIVE | ||||||||
| Address2: | HUNTERDON MEDICAL CENTER PATHOLOGY | ||||||||
| City: | FLEMINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088224613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9087886407 | ||||||||
| FaxNumber: | 9082372334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2014 | ||||||||
| LastUpdateDate: | 05/23/2017 | ||||||||
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| AuthorizedOfficialLastName: | MAGIDSON | ||||||||
| AuthorizedOfficialFirstName: | JORY | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9739715612 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 |
No ID Information.