Provider Demographics
NPI:1619977543
Name:KEDZIORA, GUY (MD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:
Last Name:KEDZIORA
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 1:100 E WAYNE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2349
Mailing Address - Country:US
Mailing Address - Phone:574-334-5390
Mailing Address - Fax:574-334-5368
Practice Address - Street 1:1915 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-9366
Practice Address - Country:US
Practice Address - Phone:574-935-2353
Practice Address - Fax:574-935-2373
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010397182085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100092080Medicaid
MI1619977543Medicaid
IN100092080Medicaid
MI1619977543Medicaid
IN236100BMedicare PIN