Provider Demographics
NPI:1851392252
Name:BASRALIAN, KEVIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:BASRALIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 ESSEX ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-8550
Mailing Address - Country:US
Mailing Address - Phone:551-996-8090
Mailing Address - Fax:551-996-8221
Practice Address - Street 1:360 ESSEX ST
Practice Address - Street 2:SUITE 403
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-8550
Practice Address - Country:US
Practice Address - Phone:551-996-8090
Practice Address - Fax:551-996-8221
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04654700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0457763OtherAETNA HMO ID #
NJ80D693OtherBC/BS NY (HACKENSACK) #
NJ4239813OtherAETNA PPO ID #
NJBS138OtherOXFORD ID #
NJ1211200Medicaid
NJ5S1641OtherBCBS NY CARLSTADT
NJ0103347000OtherAMERIHEALTH HMO ID #
NJ340001947OtherRAILROAD MDCR #
NJ80D693OtherBC/BS NY (HACKENSACK) #
NJ340001947OtherRAILROAD MDCR #