Healthcare Provider Details

I. General information

NPI: 1417116039
Provider Name (Legal Business Name): JEFFREY RADECKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 BATHGATE RD SUITE 405
BETHLEHEM PA
18017-7334
US

IV. Provider business mailing address

PO BOX 783311
PHILADELPHIA PA
19178-3311
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-3560
  • Fax: 484-884-8396
Mailing address:
  • Phone: 484-884-4500
  • Fax: 484-884-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number241308
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD448521
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: