Healthcare Provider Details

I. General information

NPI: 1326546052
Provider Name (Legal Business Name): DR. CODY LEE HEDRICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 N LEBANON ST STE 315
LEBANON IN
46052-8630
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 765-485-8855
  • Fax: 765-485-8850
Mailing address:
  • Phone: 937-257-0837
  • Fax: 937-208-8828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01082857A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: