MEDICARE: DR. BEDE A.R. PANTAZE PHD

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	103TC0700X	Clinical Psychologist	0810002816	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	245585	OTHER	VA	BLUE CROSS PIN

General Provider Information

NPI Number	:	1326005356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BEDE A.R. PANTAZE PHD

Provider Business Mailing Address
First Line	:	P.O. BOX 586
Second Line	:
City	:	GLASGOW
State	:	VA
Zip	:	24555
Country	:	US
Telephone Number	:	540-461-5555
Fax Number	:	804-741-7900

Provider Business Practice Location Address
First Line	:	9702 GAYTON RD
Second Line	:	#181
City	:	RICHMOND
State	:	VA
Zip	:	23238-4907
Country	:	US
Telephone Number	:	804-741-7500
Fax Number	:	804-741-7900

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

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	10/23/2019

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