Provider Demographics
NPI:1225030877
Name:HERDELIN, NILS G JR (MD)
Entity Type:Individual
Prefix:DR
First Name:NILS
Middle Name:G
Last Name:HERDELIN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-2511
Mailing Address - Country:US
Mailing Address - Phone:856-428-5488
Mailing Address - Fax:856-428-6716
Practice Address - Street 1:400 KINGS HWY S
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2511
Practice Address - Country:US
Practice Address - Phone:856-428-5488
Practice Address - Fax:856-428-6716
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA20517207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2708400-2Medicaid
NJEN095995Medicare ID - Type Unspecified
NJ2708400-2Medicaid