Provider Demographics
NPI:1417153677
Name:KIDS STATION PEDIATRICS
Entity Type:Organization
Organization Name:KIDS STATION PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:MORDAVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-643-7973
Mailing Address - Street 1:191 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3556
Mailing Address - Country:US
Mailing Address - Phone:860-643-7973
Mailing Address - Fax:860-643-0175
Practice Address - Street 1:191 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-3556
Practice Address - Country:US
Practice Address - Phone:860-643-7973
Practice Address - Fax:860-643-0175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2080A0000X
CT363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004132651Medicaid