Healthcare Provider Details

I. General information

NPI: 1578779450
Provider Name (Legal Business Name): RAFAL M KEDZIERSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

877 JEFFERSON AVE CHANDLER BLDG, F150
MEMPHIS TN
38103-2807
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-4454
  • Fax: 901-448-5540
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM9400
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number49857
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: