Provider Demographics
NPI:1932101516
Name:FADIL, TINA M
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:FADIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 ELM ST
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07640-1902
Mailing Address - Country:US
Mailing Address - Phone:201-784-0123
Mailing Address - Fax:201-784-0065
Practice Address - Street 1:24 ELM ST
Practice Address - Street 2:
Practice Address - City:HARRINGTON PARK
Practice Address - State:NJ
Practice Address - Zip Code:07640-1902
Practice Address - Country:US
Practice Address - Phone:201-784-0123
Practice Address - Fax:201-784-0065
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA50418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00422883OtherRAILROAD MEDICARE #
NJE53465Medicare UPIN
NJ476191C3JMedicare PIN