Healthcare Provider Details

I. General information

NPI: 1780826461
Provider Name (Legal Business Name): KENNETH T BEDOCK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 TROTWOOD AVE SUITE 401
COLUMBIA TN
38401-6433
US

IV. Provider business mailing address

854 W JAMES CAMPBELL BLVD SUITE 303A
COLUMBIA TN
38401-4659
US

V. Phone/Fax

Practice location:
  • Phone: 931-388-6550
  • Fax: 931-388-6459
Mailing address:
  • Phone: 931-540-4255
  • Fax: 931-490-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number649
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: