=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518966274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDY M BIDNER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2005
-----------------------------------------------------
Last Update Date | 12/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2405 S CLEAR CREEK RD SUITE 290
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76549-5775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-618-1555
-----------------------------------------------------
Fax | 254-618-1566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 844658
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75284-4658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-994-0371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | J1192
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------