1265613319 NPI number — BEDFORD MEDICAL ASSOCIATES

Table of content: (NPI 1265613319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265613319 NPI number — BEDFORD MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEDFORD MEDICAL ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1265613319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1305 AIRPORT FWY STE 421
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76021-6608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-685-6191
Provider Business Mailing Address Fax Number:
817-685-7133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 AIRPORT FWY
Provider Second Line Business Practice Location Address:
STE 421
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76021-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-685-6191
Provider Business Practice Location Address Fax Number:
817-685-7133
Provider Enumeration Date:
11/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
JOAN
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
817-685-6191

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  J3990 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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