Provider Demographics
NPI:1891770699
Name:BEDFORD, MARY SUSANN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSANN
Last Name:BEDFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSANN
Other - Last Name:WAMSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 631856
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 870
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1731
Practice Address - Country:US
Practice Address - Phone:404-255-2975
Practice Address - Fax:404-255-2276
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC354802086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I39703Medicare UPIN