Provider Demographics
NPI:1780826461
Name:BEDOCK, KENNETH T (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:T
Last Name:BEDOCK
Suffix:
Gender:M
Credentials:PA
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Other - Middle Name:
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Mailing Address - Street 1:854 W JAMES CAMPBELL BLVD
Mailing Address - Street 2:SUITE 303A
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4659
Mailing Address - Country:US
Mailing Address - Phone:931-540-4255
Mailing Address - Fax:931-490-4654
Practice Address - Street 1:1220 TROTWOOD AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-6433
Practice Address - Country:US
Practice Address - Phone:931-388-6550
Practice Address - Fax:931-388-6459
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN649363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical