Healthcare Provider Details

I. General information

NPI: 1174573869
Provider Name (Legal Business Name): JEFFREY D BEDRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S 17TH ST SUITE 1905
PHILADELPHIA PA
19103-6231
US

IV. Provider business mailing address

255 S 17TH ST SUITE 1905
PHILADELPHIA PA
19103-6231
US

V. Phone/Fax

Practice location:
  • Phone: 215-731-0210
  • Fax:
Mailing address:
  • Phone: 215-731-0210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD048252L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMD048252L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: