1851392252 NPI number — DR. KEVIN R BASRALIAN M.D.

Table of content: DR. KEVIN R BASRALIAN M.D. (NPI 1851392252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851392252 NPI number — DR. KEVIN R BASRALIAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASRALIAN
Provider First Name:
KEVIN
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851392252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 ESSEX ST
Provider Second Line Business Mailing Address:
SUITE 403
Provider Business Mailing Address City Name:
HACKENSACK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07601-8550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
551-996-8090
Provider Business Mailing Address Fax Number:
551-996-8221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 ESSEX ST
Provider Second Line Business Practice Location Address:
SUITE 403
Provider Business Practice Location Address City Name:
HACKENSACK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07601-8550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
551-996-8090
Provider Business Practice Location Address Fax Number:
551-996-8221
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25MA04654700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0457763 . This is a "AETNA HMO ID #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 80D693 . This is a "BC/BS NY (HACKENSACK) #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4239813 . This is a "AETNA PPO ID #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: BS138 . This is a "OXFORD ID #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1211200 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5S1641 . This is a "BCBS NY CARLSTADT" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0103347000 . This is a "AMERIHEALTH HMO ID #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 340001947 . This is a "RAILROAD MDCR #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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