1861434201 NPI number — DR. EDWARD BEDRICK M.D.

Table of content: DR. EDWARD BEDRICK M.D. (NPI 1861434201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861434201 NPI number — DR. EDWARD BEDRICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEDRICK
Provider First Name:
EDWARD
Provider Middle Name:
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:
1861434201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7500 CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19111-2430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-742-0712
Provider Business Mailing Address Fax Number:
215-742-5218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7500 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19111-2430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-742-0712
Provider Business Practice Location Address Fax Number:
215-742-5218
Provider Enumeration Date:
06/11/2006

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: 207R00000X , with the licence number:  MD025011E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 418283 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1047802 . This is a "KEYSTONE MERCY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 597586 . This is a "TPI GROUP MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0054706000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0000642 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CD4829 . This is a "TPI GROUP RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 100727800 . This is a "TPI GROUP MEDICAID ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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