MEDICARE: PETER A BIDWELL FAMILY PRACTICE

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	261QP2300X	Primary Care Clinic/Center	FO386	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0046QP	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1548483589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER A BIDWELL FAMILY PRACTICE

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	:	OWNER
Name	:	DR. PETER A BIDWELL
Credential	:	MD
Telephone Number	:	409-384-3421

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	03/12/2008

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