MEDICARE: DR. AUDREY B RADIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician	MA-57919	NJ
2	207R00000X	Internal Medicine Physician	MA-57919	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA-57919	OTHER	NJ	STATE LICENSE

General Provider Information

NPI Number	:	1134285422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUDREY B RADIN

Provider Business Mailing Address
First Line	:	80 MAIN ST STE 300
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-5439
Country	:	US
Telephone Number	:	855-619-4448
Fax Number	:	732-784-9918

Provider Business Practice Location Address
First Line	:	80 MAIN ST STE 300
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-5439
Country	:	US
Telephone Number	:	855-619-4448
Fax Number	:	732-784-9918

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	04/08/2024

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