Provider Demographics
NPI:1770530834
Name:KMC PATHOLOGY PA
Entity type:Organization
Organization Name:KMC PATHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAMESH
Authorized Official - Middle Name:C
Authorized Official - Last Name:MAHAPATRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-557-8526
Mailing Address - Street 1:PO BOX 60100
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-0100
Mailing Address - Country:US
Mailing Address - Phone:800-503-6254
Mailing Address - Fax:
Practice Address - Street 1:600 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5237
Practice Address - Country:US
Practice Address - Phone:732-363-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0895102000OtherAMERIHEALTH
1K3134OtherHEALTHNET
NJ6804802Medicaid
2037958OtherAETNA
=========OtherBLUE CROSS BLUE SHIELD
NJ6804802Medicaid
0895102000OtherAMERIHEALTH