Healthcare Provider Details

I. General information

NPI: 1184825879
Provider Name (Legal Business Name): NITI TANK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 CHAPEL AVE W
CHERRY HILL NJ
08002-2048
US

IV. Provider business mailing address

2201 CHAPEL AVE W
CHERRY HILL NJ
08002-2048
US

V. Phone/Fax

Practice location:
  • Phone: 856-488-6500
  • Fax: 856-922-5109
Mailing address:
  • Phone: 856-488-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD442160
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA09034800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: