Provider Demographics
NPI:1891728861
Name:BAY DERMATOLOGY ASSOCIATES JERRY L HEDRICK MD PA
Entity Type:Organization
Organization Name:BAY DERMATOLOGY ASSOCIATES JERRY L HEDRICK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:HEDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:813-685-0306
Mailing Address - Street 1:500 VONDERBURG DRIVE
Mailing Address - Street 2:STE 115W
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5969
Mailing Address - Country:US
Mailing Address - Phone:813-685-0306
Mailing Address - Fax:813-651-1026
Practice Address - Street 1:500 VONDERBURG DRIVE
Practice Address - Street 2:STE 115W
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5969
Practice Address - Country:US
Practice Address - Phone:813-685-0306
Practice Address - Fax:813-651-1026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38730207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0667336OtherAETNA
FL30425OtherBLUE CROSS BLUE SHIELD
FL070000215OtherRAILROAD MEDICARE
FL30425OtherBLUE CROSS BLUE SHIELD
FLK8018Medicare ID - Type Unspecified
FL0667336OtherAETNA