MEDICARE: TINA M PETILLO DO

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	207V00000X	Obstetrics & Gynecology Physician	44503	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962437244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA M PETILLO DO

Provider Business Mailing Address
First Line	:	340 E NORTHFIELD RD STE 2E
Second Line	:
City	:	LIVINGSTON
State	:	NJ
Zip	:	07039-4892
Country	:	US
Telephone Number	:	973-533-0001
Fax Number	:

Provider Business Practice Location Address
First Line	:	340 EAST NORTHFIELD ROAD
Second Line	:	SUITE 2E
City	:	LIVINGSTON
State	:	NJ
Zip	:	07039-4892
Country	:	US
Telephone Number	:	973-533-0001
Fax Number	:	973-716-0306

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	03/30/2011

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Directions to “ TINA M PETILLO DO” Practice Location

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