Provider Demographics
NPI:1588607774
Name:KIDSMED LLC
Entity Type:Organization
Organization Name:KIDSMED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:COOLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-743-3784
Mailing Address - Street 1:1331 E WYOMING AVE
Mailing Address - Street 2:3100
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3808
Mailing Address - Country:US
Mailing Address - Phone:215-743-3784
Mailing Address - Fax:215-743-3781
Practice Address - Street 1:1331 E WYOMING AVE
Practice Address - Street 2:3100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3808
Practice Address - Country:US
Practice Address - Phone:215-743-3784
Practice Address - Fax:215-743-3781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA33535Medicare UPIN