Healthcare Provider Details

I. General information

NPI: 1891728861
Provider Name (Legal Business Name): BAY DERMATOLOGY ASSOCIATES JERRY L HEDRICK MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VONDERBURG DRIVE STE 115W
BRANDON FL
33511-5969
US

IV. Provider business mailing address

500 VONDERBURG DRIVE STE 115W
BRANDON FL
33511-5969
US

V. Phone/Fax

Practice location:
  • Phone: 813-685-0306
  • Fax: 813-651-1026
Mailing address:
  • Phone: 813-685-0306
  • Fax: 813-651-1026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME38730
License Number StateFL

VIII. Authorized Official

Name: JERRY LEO HEDRICK
Title or Position: PHYSICIAN
Credential: MD PA
Phone: 813-685-0306