Provider Demographics
NPI:1477651487
Name:MCNEILL, ROBERTA NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:NICOLE
Last Name:MCNEILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 CEDAR LANE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-0000
Mailing Address - Country:US
Mailing Address - Phone:201-836-7664
Mailing Address - Fax:201-836-5710
Practice Address - Street 1:780 CEDAR LANE
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-0000
Practice Address - Country:US
Practice Address - Phone:201-836-7664
Practice Address - Fax:201-836-5710
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI 04511Medicare UPIN