Basic Information
| Provider Information | |||||||||
| NPI: | 1194784603 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEDO | ||||||||
| FirstName: | ABDULRAZAK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSHVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461731116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659324111 | ||||||||
| FaxNumber: | 7659327062 | ||||||||
| Practice Location | |||||||||
| Address1: | 1339 N CHERRY STREET | ||||||||
| Address2: | |||||||||
| City: | RUSHVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461731116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659327000 | ||||||||
| FaxNumber: | 7659327001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | IN01052945 | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 01052945A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01052945 | 01 | IN | LICENSE | OTHER | 000000373848 | 01 | IN | ANTHEM | OTHER | 200319580 | 05 | IN | MEDICAID |