Provider Demographics
NPI:1811161557
Name:TINA M. PETILLO DO PA
Entity type:Organization
Organization Name:TINA M. PETILLO DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-533-0001
Mailing Address - Street 1:340 E NORTHFIELD RD
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-4892
Mailing Address - Country:US
Mailing Address - Phone:973-533-0001
Mailing Address - Fax:973-716-0306
Practice Address - Street 1:340 E NORTHFIELD RD
Practice Address - Street 2:SUITE 2E
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4892
Practice Address - Country:US
Practice Address - Phone:973-533-0001
Practice Address - Fax:973-716-0306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04450300207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ699300Medicare PIN