Provider Demographics
NPI:1366647703
Name:KEDRA, BRIAN MICHAEL (DPT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:KEDRA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:73 OLD DUBLIN PIKE STE 6
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2491
Practice Address - Country:US
Practice Address - Phone:215-489-1701
Practice Address - Fax:215-489-1705
Is Sole Proprietor?:No
Enumeration Date:2007-06-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10002272225100000X
PAPT018889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1366647703OtherTRICARE CHAMPUS
DE1366647703Medicaid
2872734000OtherAMERIHEALTH IBC
92830401OtherNCA
5070-0085OtherCARE FIRST
11796745OtherCAQH
2066834OtherPA BS
2872734000OtherIBC AMERIHEALTH
92830401OtherNCA
2872734000OtherIBC AMERIHEALTH
11796745OtherCAQH