Provider Demographics
NPI:1245250398
Name:BEDWELL, KEVIN W (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:BEDWELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 S TOLLGATE RD STE 207
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-5902
Mailing Address - Country:US
Mailing Address - Phone:443-371-9750
Mailing Address - Fax:443-371-9751
Practice Address - Street 1:2012 S TOLLGATE RD STE 207
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-5902
Practice Address - Country:US
Practice Address - Phone:443-371-9750
Practice Address - Fax:443-371-9751
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC00023162081P2900X, 363AS0400X
PAMA050944363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
104752OtherMEDICARE
P89706Medicare UPIN