Provider Demographics
NPI:1851390223
Name:NIEDBALA, THOMAS M (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:NIEDBALA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 1710
Mailing Address - Street 2:SOUTH JERSEY RADIOLOGY ASSOCIATES, PA
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-7710
Mailing Address - Country:US
Mailing Address - Phone:856-770-0504
Mailing Address - Fax:856-770-0395
Practice Address - Street 1:100 CARNIE BLVD
Practice Address - Street 2:SUITE B-5
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4512
Practice Address - Country:US
Practice Address - Phone:856-751-0123
Practice Address - Fax:856-751-0535
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA059344002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4603401Medicaid
A3738029OtherOXFORD HEALTH
NI747400OtherPREMIER BLUE
1388808OtherUNITED HEALTHCARE
0656838000OtherAMERIHEALTH
300069412OtherRAILROAD MEDICARE
0733044OtherAETNA
1089830OtherHORIZON NJ HEALTH
NI747400OtherHIGHMARK PA BLUE SHIELD
0656838000OtherAMERIHEALTH
NJE58966Medicare UPIN