Basic Information
| Provider Information | |||||||||
| NPI: | 1245250398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEDWELL | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 514 GIFFORD LN | ||||||||
| Address2: | |||||||||
| City: | MONKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211111004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434913721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | 5TH FLOOR SCHOENEMAN BUILDING | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106018500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 02/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OA002145 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | MA050944 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | C0002316 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 104752 | 01 | MEDICARE | OTHER |