=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710540315
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHEA MARIE COMADOLL MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2019
-----------------------------------------------------
Last Update Date | 09/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 TOWN SQUARE PL STE 208
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07310-2778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-322-7330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 379 CAMPUS DR FL 4
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08873-1161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-937-8939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 25MA12051000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------