Provider Demographics
NPI:1962515239
Name:CELLDOX INC
Entity type:Organization
Organization Name:CELLDOX INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROISUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-248-0226
Mailing Address - Street 1:6470 INTERSTATE CT
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6759
Mailing Address - Country:US
Mailing Address - Phone:573-248-0226
Mailing Address - Fax:
Practice Address - Street 1:6470 INTERSTATE CT
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6759
Practice Address - Country:US
Practice Address - Phone:573-248-0826
Practice Address - Fax:573-221-2252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00166253207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501875306Medicaid
MO501875306Medicaid