Basic Information
| Provider Information | |||||||||
| NPI: | 1972758142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FADEN | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | B. | ||||||||
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| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2250 CHAPEL AVE W | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564829000 | ||||||||
| FaxNumber: | 8564821159 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 CHAPEL AVE W | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564829000 | ||||||||
| FaxNumber: | 8564821159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 25MB08863700 | NJ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | OS018244 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0294420 | 05 | NJ | MEDICAID |