Provider Demographics
NPI:1679581284
Name:EDMONSTON, TINA B (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:B
Last Name:EDMONSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 FEDERAL ST
Mailing Address - Street 2:SUITE 437
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1061
Mailing Address - Country:US
Mailing Address - Phone:856-963-0573
Mailing Address - Fax:856-541-6037
Practice Address - Street 1:200 FEDERAL ST
Practice Address - Street 2:SUITE 437
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1061
Practice Address - Country:US
Practice Address - Phone:856-963-0573
Practice Address - Fax:856-541-6037
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421051207ZP0007X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101103749Medicaid
NJ0043141Medicaid
PA101103749Medicaid