Healthcare Provider Details

I. General information

NPI: 1063462414
Provider Name (Legal Business Name): DANIEL J BEDECKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 S 6TH ST STE 204
TERRE HAUTE IN
47807
US

IV. Provider business mailing address

1024 S 6TH ST STE 204
TERRE HAUTE IN
47807
US

V. Phone/Fax

Practice location:
  • Phone: 812-234-7128
  • Fax: 812-231-0104
Mailing address:
  • Phone: 812-234-7128
  • Fax: 812-231-0104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01032307B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: