Provider Demographics
NPI:1861434201
Name:BEDRICK, EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:BEDRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 CENTRAL AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2430
Mailing Address - Country:US
Mailing Address - Phone:215-742-0712
Mailing Address - Fax:215-742-5218
Practice Address - Street 1:7500 CENTRAL AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2430
Practice Address - Country:US
Practice Address - Phone:215-742-0712
Practice Address - Fax:215-742-5218
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025011E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
418283OtherBLUE SHIELD
1047802OtherKEYSTONE MERCY
PA597586OtherTPI GROUP MEDICARE PTAN
PA0054706000OtherKEYSTONE
PA0000642OtherAETNA
PACD4829OtherTPI GROUP RAILROAD MEDICARE
PA100727800OtherTPI GROUP MEDICAID ID
PA418283F2GMedicare ID - Type Unspecified
PA0000642OtherAETNA