Healthcare Provider Details

I. General information

NPI: 1114343605
Provider Name (Legal Business Name): REBECCA JANE BEDARD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2014
Last Update Date: 03/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 EXECUTIVE PARK S SUITE 1000
ATLANTA GA
30329-2208
US

IV. Provider business mailing address

1015 PIEDMONT AVE NE APT C4
ATLANTA GA
30309-3732
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-7137
  • Fax:
Mailing address:
  • Phone: 413-237-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number2000001376
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number13-0618
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: