MEDICARE: KEITH A BEDNARCZUK OD INC

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	3215/T351	OH

General Provider Information

NPI Number	:	1104139807
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH A BEDNARCZUK OD INC

Provider Business Mailing Address
First Line	:	777 COLUMBUS AVE
Second Line	:	SUITE 12
City	:	LEBANON
State	:	OH
Zip	:	45036-1684
Country	:	US
Telephone Number	:	513-932-3343
Fax Number	:	513-932-0078

Provider Business Practice Location Address
First Line	:	777 COLUMBUS AVE
Second Line	:	SUITE 12
City	:	LEBANON
State	:	OH
Zip	:	45036-1684
Country	:	US
Telephone Number	:	513-932-3343
Fax Number	:	513-932-0078

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEITH A BEDNARCZUK
Credential	:	O.D.
Telephone Number	:	513-932-3343

Provider Enumeration Date	:	07/22/2010
Last Update Date	:	08/04/2010

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