Basic Information
| Provider Information | |||||||||
| NPI: | 1942290705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEDNARZ | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 DOCTORS DR | ||||||||
| Address2: | STE. 106 | ||||||||
| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302404132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068459370 | ||||||||
| FaxNumber: | 7068459371 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 N MEDICAL PKWY | ||||||||
| Address2: | BLDG 100, SUITE 102 | ||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301897062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709264641 | ||||||||
| FaxNumber: | 7709261692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 03/13/2012 | ||||||||
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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 | 213ES0103X | POD001030 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 908119435A | 05 | GA | MEDICAID | 1756326 | 05 | LA | MEDICAID |