MEDICARE: KEVIN BRADLEY CEDERBERG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	M6070	TX
2	2085P0229X	Pediatric Radiology Physician	M6070	TX
3	2085R0204X	Vascular & Interventional Radiology Physician	M6070	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BP1-0018147	OTHER		INSTITUTIONAL PERMIT

General Provider Information

NPI Number	:	1104020296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN BRADLEY CEDERBERG MD

Provider Business Mailing Address
First Line	:	5323 HARRY HINES BLVD
Second Line	:	DEPARTMENT OF RADIOLOGY
City	:	DALLAS
State	:	TX
Zip	:	75390-8896
Country	:	US
Telephone Number	:	214-648-8004
Fax Number	:

Provider Business Practice Location Address
First Line	:	5323 HARRY HINES BLVD
Second Line	:	DEPARTMENT OF RADIOLOGY
City	:	DALLAS
State	:	TX
Zip	:	75390-8896
Country	:	US
Telephone Number	:	214-648-8004
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	10/16/2023

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