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General NPI Number Information
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NPI Number | 1417186305
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Entity Type | Individual
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Provider Name | BRENT J BEDKE MD
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Gender | Male
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Dates
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Enumeration Date | 07/13/2009
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 1740 SYCAMORE AVE STE C
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City | KINGMAN
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State | AZ
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Zip | 86409-1039
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Country | US
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Telephone | 507-284-2511
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Fax |
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Provider Business Mailing Address
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Address Line | 1740 SYCAMORE AVE STE C
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City | KINGMAN
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State | AZ
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Zip | 86409-1039
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Country | US
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Telephone | 507-284-2511
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0105X
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Taxonomy Name | Clinical Pathology/Laboratory Medicine Physician
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License Number | 52935
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 48849
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License Number State | AZ
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