Healthcare Provider Details

I. General information

NPI: 1982173654
Provider Name (Legal Business Name): KATHERINE MARIE FOMCHENKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2018
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RIVERVIEW PLZ
RED BANK NJ
07701-1864
US

IV. Provider business mailing address

5700 SOUTHWYCK BLVD
TOLEDO OH
43614-1509
US

V. Phone/Fax

Practice location:
  • Phone: 732-741-2700
  • Fax:
Mailing address:
  • Phone: 800-288-8325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number25MA13004200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: