Provider Demographics
NPI:1316225097
Name:MOUNTAIN LAKES PATHOLOGY LLC
Entity Type:Organization
Organization Name:MOUNTAIN LAKES PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ESSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-831-5046
Mailing Address - Street 1:115 ROUTE 46 W
Mailing Address - Street 2:SUITE B-12
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1668
Mailing Address - Country:US
Mailing Address - Phone:973-809-7706
Mailing Address - Fax:
Practice Address - Street 1:115 ROUTE 46 W
Practice Address - Street 2:SUITE B-12
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1668
Practice Address - Country:US
Practice Address - Phone:973-809-7706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8606005Medicaid
NJ8065301Medicaid
NJ8065301Medicaid