Provider Demographics
NPI:1366647703
Name:KEDRA, BRIAN MICHAEL (DPT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:KEDRA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:73 OLD DUBLIN PIKE STE 6
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2491
Practice Address - Country:US
Practice Address - Phone:215-489-1701
Practice Address - Fax:215-489-1705
Is Sole Proprietor?:No
Enumeration Date:2007-06-17
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10002272225100000X
PAPT018889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11796745OtherCAQH
2066834OtherPA BS
DE1366647703Medicaid
1366647703OtherTRICARE CHAMPUS
2872734000OtherAMERIHEALTH IBC
5070-0085OtherCARE FIRST
92830401OtherNCA
2872734000OtherIBC AMERIHEALTH
92830401OtherNCA
2872734000OtherIBC AMERIHEALTH
11796745OtherCAQH