Provider Demographics
NPI:1407013121
Name:KIDMED INC.
Entity Type:Organization
Organization Name:KIDMED INC.
Other - Org Name:KIDMED WEST END
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:FLANZENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-592-5437
Mailing Address - Street 1:4687 POUNCEY TRACT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5802
Mailing Address - Country:US
Mailing Address - Phone:804-422-5437
Mailing Address - Fax:
Practice Address - Street 1:4687 POUNCEY TRACT RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5802
Practice Address - Country:US
Practice Address - Phone:804-647-2240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDMED INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-20
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF16860Medicare UPIN
VAG39610Medicare UPIN
VAF87004Medicare UPIN