Basic Information
| Provider Information | |||||||||
| NPI: | 1689011108 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEDWARD | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055002000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12953 PALMS WEST DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | LOXAHATCHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334704991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617931713 | ||||||||
| FaxNumber: | 8882179051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2013 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD176995 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.