Healthcare Provider Details

I. General information

NPI: 1952367740
Provider Name (Legal Business Name): JOHN MORRIS BEDWINEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MEDICAL PLZ STE 100
LAKE ST LOUIS MO
63367-1493
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-695-2316
  • Fax: 636-639-8676
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberR8484
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: