Basic Information
| Provider Information | |||||||||
| NPI: | 1023019312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PILLA | ||||||||
| FirstName: | TIMOTHY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 EVES DR | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080533193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566696061 | ||||||||
| FaxNumber: | 8566510853 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 W RED BANK AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080961630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568488242 | ||||||||
| FaxNumber: | 8563846015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 02/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MA05024600 | NJ | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 25MA05024600 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2204207 | 05 | NJ | MEDICAID |