1184808065 NPI number — WALTER J M PEDERSEN JR MD PC

Table of content: (NPI 1184808065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184808065 NPI number — WALTER J M PEDERSEN JR MD PC

Organization/Personal Information

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

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:
1184808065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2012
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:
Provider Business Mailing Address City Name:
CHRISTIANSTED
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 PROF BLDG
Provider Second Line Business Practice Location Address:
SUITE 3F
Provider Business Practice Location Address City Name:
ST CROIX
Provider Business Practice Location Address State Name:
VI
Provider Business Practice Location Address Postal Code:
00823-4423
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:
12/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PEDERSEN
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
J M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
340-778-6110

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  653 , registered in the state of VI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , 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: VI000011 . This is a "TRICARE" 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".
  • Identifier: 170823200 . This is a "USDL" 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 "BCBSVI" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".
  • Identifier: 1184808065 . This is a "NPI" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".




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