Healthcare Provider Details

I. General information

NPI: 1417153677
Provider Name (Legal Business Name): KIDS STATION PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 MAIN ST
MANCHESTER CT
06042-3556
US

IV. Provider business mailing address

191 MAIN ST
MANCHESTER CT
06042-3556
US

V. Phone/Fax

Practice location:
  • Phone: 860-643-7973
  • Fax: 860-643-0175
Mailing address:
  • Phone: 860-643-7973
  • Fax: 860-643-0175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number StateCT

VIII. Authorized Official

Name: DR. DONALD FRANCIS MORDAVSKY
Title or Position: CEO
Credential: MD
Phone: 860-643-7973