MEDICARE: DR. PETER ALEXANDER BIDWELL MD

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	207Q00000X	Family Medicine Physician	FO386	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8AJ761	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1487650420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER ALEXANDER BIDWELL MD

Provider Business Mailing Address
First Line	:	1007 DICKERSON DR
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-5110
Country	:	US
Telephone Number	:	409-384-3421
Fax Number	:	409-384-7443

Provider Business Practice Location Address
First Line	:	1007 DICKERSON DR
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-5110
Country	:	US
Telephone Number	:	409-384-3421
Fax Number	:	409-384-7443

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	01/08/2010

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