Basic Information
Provider Information | |||||||||
NPI: | 1407849342 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TEDRICK | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1300 MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323084646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502160100 | ||||||||
FaxNumber: | 8502014834 | ||||||||
Practice Location | |||||||||
Address1: | 1300 MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323084646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502160100 | ||||||||
FaxNumber: | 8502014834 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2005 | ||||||||
LastUpdateDate: | 07/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME29338 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 015832 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | ME29338 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 009979030 | 05 | AL |   | MEDICAID | 00000 | 01 | FL | UNITED HEALTH CARE | OTHER | 37230 | 01 | FL | BCBS | OTHER | 00000 | 01 | FL | FOCUS | OTHER | 00000 | 01 | FL | SOUTHCARE | OTHER | 00000 | 01 | GA | VISTA | OTHER | 00000 | 01 | FL | UNIVERSAL HEALTH CARE | OTHER | 00000 | 01 | FL | BEECH STREET/CAPP CARE | OTHER | 058454100 | 05 | FL |   | MEDICAID | 00000 | 01 | FL | HUMANA/CHOICE CARE | OTHER | 000164898A | 05 | GA |   | MEDICAID |