Healthcare Provider Details

I. General information

NPI: 1801156062
Provider Name (Legal Business Name): TRI-STATE PATHOLOGY CONSULTANTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 HADDON AVE PATHOLOGY DEPARTMENT
CAMDEN NJ
08103-3101
US

IV. Provider business mailing address

219 THOMAS AVE ATTN: CREDENTIALING-COLEEN SCHICKLING
RIVERTON NJ
08077-1225
US

V. Phone/Fax

Practice location:
  • Phone: 856-757-3564
  • Fax: 856-757-3955
Mailing address:
  • Phone: 609-649-3261
  • Fax: 856-829-3107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207ZI0100X
TaxonomyImmunopathology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207ZM0300X
TaxonomyMedical Microbiology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code207ZP0104X
TaxonomyChemical Pathology Physician
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number
License Number State
# 13
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number25MA09091300
License Number StateNJ

VIII. Authorized Official

Name: DR. NABIL AL-ANNOUF
Title or Position: OWNER
Credential: M.D.
Phone: 856-757-3564