Healthcare Provider Details

I. General information

NPI: 1689189300
Provider Name (Legal Business Name): IMAR DERM PATH LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 LACEY RD STE 2A
FORKED RIVER NJ
08731-1532
US

IV. Provider business mailing address

1580 LAKEWOOD RD STE 16
TOMS RIVER NJ
08755-3287
US

V. Phone/Fax

Practice location:
  • Phone: 732-456-7777
  • Fax: 848-251-2189
Mailing address:
  • Phone: 732-456-7777
  • Fax: 848-251-2189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number25MA03772900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number25MA09002600
License Number StateNJ

VIII. Authorized Official

Name: DR. RAMI GEFFNER
Title or Position: OWNER
Credential: MD
Phone: 732-456-7777