Provider Demographics
NPI:1528184439
Name:BEDFORD PEDIATRICS, P.A.
Entity Type:Organization
Organization Name:BEDFORD PEDIATRICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERMIT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNELLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-471-0831
Mailing Address - Street 1:360 ROUTE 101
Mailing Address - Street 2:UNIT 7B
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-5030
Mailing Address - Country:US
Mailing Address - Phone:603-471-0831
Mailing Address - Fax:603-471-0890
Practice Address - Street 1:360 ROUTE 101
Practice Address - Street 2:UNIT 7B
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-5030
Practice Address - Country:US
Practice Address - Phone:603-471-0831
Practice Address - Fax:603-471-0890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30210849Medicaid