Provider Demographics
NPI:1952367740
Name:BEDWINEK, JOHN MORRIS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MORRIS
Last Name:BEDWINEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 MEDICAL PLZ STE 100
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1493
Practice Address - Country:US
Practice Address - Phone:636-695-2316
Practice Address - Fax:636-639-8676
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR84842085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201801628Medicaid
49795OtherGHP
4119583OtherAETNA
MO107975OtherBCBS
2409021OtherUHC
900001981OtherRR MEDICARE
900001981OtherRR MEDICARE
4119583OtherAETNA