1629151428 NPI number — JEFFREY R PEDERSEN DO

Table of content: JEFFREY R PEDERSEN DO (NPI 1629151428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629151428 NPI number — JEFFREY R PEDERSEN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDERSEN
Provider First Name:
JEFFREY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1629151428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14402 E SPRAGUE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99216-2167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-922-2625
Provider Business Mailing Address Fax Number:
509-922-4001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14402 E SPRAGUE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99216-2167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-922-2625
Provider Business Practice Location Address Fax Number:
509-922-4001
Provider Enumeration Date:
10/23/2006

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: 207Q00000X , with the licence number:  O221 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: OP00001642 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 129223 . This is a "WA LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: S3143 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010005518 . This is a "REGENCE BLUESHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1043078 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 805453200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1301819 . This is a "DMERC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805453200 . This is a "HEALTHY CONNECTIONS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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