Provider Demographics
NPI:1184661407
Name:BEDNARZ, MICHAEL PAUL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:BEDNARZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1601 WEST JACKSON STREET
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455
Mailing Address - Country:US
Mailing Address - Phone:309-575-3222
Mailing Address - Fax:309-404-8000
Practice Address - Street 1:1601 WEST JACKSON STREET
Practice Address - Street 2:SUITE 104
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455
Practice Address - Country:US
Practice Address - Phone:309-575-3222
Practice Address - Fax:309-404-8000
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0361007802084P0800X
IL361007802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100780Medicaid
ILH05058Medicare UPIN
IL036100780Medicaid
IL5379001Medicare UPIN