Provider Demographics
NPI:1356377105
Name:KALEIDOSCOPE MEDICAL ASSOCIATES, PA
Entity type:Organization
Organization Name:KALEIDOSCOPE MEDICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANA
Authorized Official - Middle Name:P
Authorized Official - Last Name:GOMES
Authorized Official - Suffix:
Authorized Official - Credentials:DO, CMD
Authorized Official - Phone:908-454-9902
Mailing Address - Street 1:410 COVENTRY CENTRE DR.
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865
Mailing Address - Country:US
Mailing Address - Phone:908-454-9902
Mailing Address - Fax:908-454-9902
Practice Address - Street 1:410 COVENTRY DR
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1978
Practice Address - Country:US
Practice Address - Phone:908-454-9902
Practice Address - Fax:908-454-9905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB065920207Q00000X
NJNN095449NJ363L00000X
NJ25MB077888000207Q00000X
NJ25MA06829400207Q00000X
NJMB064321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7437307Medicaid
NJ8313407Medicaid
NJ7387601Medicaid
NJ0057908Medicaid
PA119772OtherMEDICARE PA
NJ8440506Medicaid
NJ041113OtherMEDICARE NJ
NJH23044Medicare UPIN
NJ002345Medicare ID - Type UnspecifiedANA GOMES
NJ7437307Medicaid
NJ7387601Medicaid
NJ8313407Medicaid
NJ041113OtherMEDICARE NJ
NJG60187Medicare UPIN
PA080924Medicare ID - Type UnspecifiedCECILIA RAI
NJG54773Medicare UPIN
NJ0057908Medicaid