Provider Demographics
NPI:1851489363
Name:BEDLACK, RICHARD STANLEY JR (MD PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:STANLEY
Last Name:BEDLACK
Suffix:JR
Gender:M
Credentials:MD PHD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:9 LOGGING TRL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-4656
Mailing Address - Country:US
Mailing Address - Phone:919-668-2373
Mailing Address - Fax:
Practice Address - Street 1:501 FULTON STREET
Practice Address - Street 2:BOX 111J
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705
Practice Address - Country:US
Practice Address - Phone:919-286-0411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000-001832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH26785Medicare UPIN
NC2013477Medicare PIN