Healthcare Provider Details

I. General information

NPI: 1487769154
Provider Name (Legal Business Name): ANTHONY BEDEAR PETRO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST SUITE 500
JACKSON MS
39202-1651
US

IV. Provider business mailing address

501 MARSHALL ST SUITE 500
JACKSON MS
39202-1651
US

V. Phone/Fax

Practice location:
  • Phone: 601-948-1411
  • Fax: 601-948-0090
Mailing address:
  • Phone: 601-948-1411
  • Fax: 601-948-0090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number05828
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: