Healthcare Provider Details

I. General information

NPI: 1417186305
Provider Name (Legal Business Name): BRENT J BEDKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 SYCAMORE AVE STE C
KINGMAN AZ
86409-1039
US

IV. Provider business mailing address

1740 SYCAMORE AVE STE C
KINGMAN AZ
86409-1039
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-2511
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number52935
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number48849
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: