1780671909 NPI number — DR. WALTER JM PEDERSEN JR. MD

Table of content: DR. WALTER JM PEDERSEN JR. MD (NPI 1780671909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780671909 NPI number — DR. WALTER JM PEDERSEN JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDERSEN
Provider First Name:
WALTER
Provider Middle Name:
JM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780671909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7840
Provider Second Line Business Mailing Address:
SUNNY ISLE PROFESSIONAL BLDG, STE 3
Provider Business Mailing Address City Name:
ST CROIX
Provider Business Mailing Address State Name:
VI
Provider Business Mailing Address Postal Code:
00823-7840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
340-778-6110
Provider Business Mailing Address Fax Number:
340-778-2919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SUNNY ISLE PROFESSIONAL BUILDING
Provider Second Line Business Practice Location Address:
SUITE 3-F
Provider Business Practice Location Address City Name:
ST. CROIX
Provider Business Practice Location Address State Name:
VI
Provider Business Practice Location Address Postal Code:
00820-4423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
340-778-6110
Provider Business Practice Location Address Fax Number:
340-778-2919
Provider Enumeration Date:
10/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  653 , registered in the state of VI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: V1000011 . This is a "TRICARE" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".
  • Identifier: 1780671909 . This is a "NPI" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".
  • Identifier: 53699PE . This is a "TRIPLE S" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".
  • Identifier: 089045 . This is a "BLUE CROSS BLUE SHIELD VI" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".
  • Identifier: 0500138 . This is a "HUMANA" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".




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