Healthcare Provider Details

I. General information

NPI: 1568471472
Provider Name (Legal Business Name): JILL GARRIPOLI PEDALINO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 FRANKLIN AVE
NUTLEY NJ
07110-1209
US

IV. Provider business mailing address

675 FRANKLIN AVE
NUTLEY NJ
07110-1209
US

V. Phone/Fax

Practice location:
  • Phone: 844-437-5455
  • Fax: 844-437-5455
Mailing address:
  • Phone: 844-437-5455
  • Fax: 862-238-7454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MB07995400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: