Healthcare Provider Details

I. General information

NPI: 1326045295
Provider Name (Legal Business Name): KSYMENA KEDZIERSKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4C DOCTORS PARK
HACKETTSTOWN NJ
07840-1716
US

IV. Provider business mailing address

4 DOCTORS PARK SUITE C
HACKETTSTOWN NJ
07840-1716
US

V. Phone/Fax

Practice location:
  • Phone: 908-852-8096
  • Fax: 908-852-5012
Mailing address:
  • Phone: 908-852-8096
  • Fax: 908-852-5012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07788100
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0060691
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: