Provider Demographics
NPI:1689189300
Name:IMAR DERM PATH LABORATORY LLC
Entity Type:Organization
Organization Name:IMAR DERM PATH LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:GEFFNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-456-7777
Mailing Address - Street 1:1580 LAKEWOOD RD STE 16
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-3287
Mailing Address - Country:US
Mailing Address - Phone:732-456-7777
Mailing Address - Fax:848-251-2189
Practice Address - Street 1:540 LACEY RD STE 2A
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1532
Practice Address - Country:US
Practice Address - Phone:732-456-7777
Practice Address - Fax:848-251-2189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03772900207ND0900X
NJ25MA09002600207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty