Provider Demographics
NPI:1649251224
Name:KEARNS, MARTHA SLADE (MD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:SLADE
Last Name:KEARNS
Suffix:
Gender:F
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:C/O BWR INNOVATIONS 3471 S. UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-552-5271
Mailing Address - Fax:
Practice Address - Street 1:300 LACKAWANNA AVE STE 200
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-2001
Practice Address - Country:US
Practice Address - Phone:570-342-7864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0418262085R0202X
ND106512085R0202X
PAMD4633732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14287Medicaid
CT001418260Medicaid
PA103463715Medicaid
CT001418260Medicaid
CT300003662Medicare ID - Type Unspecified