Healthcare Provider Details

I. General information

NPI: 1629483508
Provider Name (Legal Business Name): MARY RATLIFF KEDROWSKI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 NW MEDICAL CENTER LN
LAKE CITY FL
32055-4717
US

IV. Provider business mailing address

3140 NW MEDICAL CENTER LN STE 120
LAKE CITY FL
32055-4735
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-6682
  • Fax: 386-755-6796
Mailing address:
  • Phone: 386-755-6682
  • Fax: 386-755-6796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS15936
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: