Provider Demographics
NPI:1386856029
Name:KIDKARE MEDICAL PA
Entity Type:Organization
Organization Name:KIDKARE MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-773-6171
Mailing Address - Street 1:15-01 BROADWAY STE 36
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-6006
Mailing Address - Country:US
Mailing Address - Phone:201-773-6171
Mailing Address - Fax:201-773-4845
Practice Address - Street 1:15-01 BROADWAY STE 36
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6006
Practice Address - Country:US
Practice Address - Phone:201-773-6171
Practice Address - Fax:201-773-4845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07639000261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0081787Medicaid
NJ1346212156OtherINDIVIDUAL NPI
NJ0081787Medicaid
NJ149124Medicare UPIN