MEDICARE: JACK T HEDRICK OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18001316A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000350877	OTHER	IN	ANTHEM BCBS
2	18001316A	OTHER	IN	OD LICENSE NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053303198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK T HEDRICK OD

Provider Business Mailing Address
First Line	:	600 S MAIN ST
Second Line	:
City	:	SALEM
State	:	IN
Zip	:	47167-1040
Country	:	US
Telephone Number	:	812-883-2700
Fax Number	:	812-883-2752

Provider Business Practice Location Address
First Line	:	600 S MAIN ST
Second Line	:
City	:	SALEM
State	:	IN
Zip	:	47167-1040
Country	:	US
Telephone Number	:	812-883-2700
Fax Number	:	812-883-2752

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	10/01/2008

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