Healthcare Provider Details

I. General information

NPI: 1619953981
Provider Name (Legal Business Name): KIDS CARE PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6529 BLACK HORSE PK
EGG HARBOR TWP NJ
08234-4509
US

IV. Provider business mailing address

22 NORTH FRANKLIN AVENUE 2ND FLOOR
PLEASANTVILLE NJ
08232
US

V. Phone/Fax

Practice location:
  • Phone: 609-645-8500
  • Fax: 609-645-2574
Mailing address:
  • Phone: 609-272-0655
  • Fax: 609-272-9317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3200903
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: JON M REGIS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 609-272-0655