Provider Demographics
NPI:1104860857
Name:BEDFORD RADIOLOGY, PLLC
Entity Type:Organization
Organization Name:BEDFORD RADIOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-660-1485
Mailing Address - Street 1:250 E CARMEL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-2635
Mailing Address - Country:US
Mailing Address - Phone:317-660-1485
Mailing Address - Fax:317-282-0589
Practice Address - Street 1:2257 WILMA RUDOLPH BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6194
Practice Address - Country:US
Practice Address - Phone:317-660-1485
Practice Address - Fax:317-282-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3377880Medicaid
TN3377880Medicaid