Healthcare Provider Details

I. General information

NPI: 1871571554
Provider Name (Legal Business Name): DESHA D BEDFORD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DESHA KELLY MD

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEMORIAL AVE CARROLL HOSPITAL CENTER
WESTMINSTER MD
21157-5726
US

IV. Provider business mailing address

10227 DOTTYS WAY
COLUMBIA MD
21044-3886
US

V. Phone/Fax

Practice location:
  • Phone: 410-871-6700
  • Fax: 410-871-7177
Mailing address:
  • Phone: 301-921-7900
  • Fax: 301-921-7915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0062362
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0062362
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: