Provider Demographics
NPI:1013218510
Name:STEFAN A KIEDROWSKI, MD, PA
Entity Type:Organization
Organization Name:STEFAN A KIEDROWSKI, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEFAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIEDROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-878-1044
Mailing Address - Street 1:1879 PROFESSIONAL PARK CIR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4506
Mailing Address - Country:US
Mailing Address - Phone:850-878-1044
Mailing Address - Fax:850-656-7504
Practice Address - Street 1:1879 PROFESSIONAL PARK CIR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4506
Practice Address - Country:US
Practice Address - Phone:850-878-1044
Practice Address - Fax:850-656-7504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40345174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066468500Medicaid