Basic Information
| Provider Information | |||||||||
| NPI: | 1801980784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIDWELL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377522305 | ||||||||
| FaxNumber: | 9375227513 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 SOUTHERN BLVD | ||||||||
| Address2: | SUITE 4100 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958444 | ||||||||
| FaxNumber: | 9373958450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/28/2014 | ||||||||
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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 | 207VE0102X | 35052666 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 884330E | 01 | AMERICAN BD. OF OBGYN | OTHER | 0599946 | 05 | OH | MEDICAID | 38587 | 01 | OH | NO.CAROLINA LICENSE NO. | OTHER |