1386866234 NPI number — MR. JAN PEDERSEN BOCO ORTHOTIST

Table of content: MR. JAN PEDERSEN BOCO ORTHOTIST (NPI 1386866234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386866234 NPI number — MR. JAN PEDERSEN BOCO ORTHOTIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDERSEN
Provider First Name:
JAN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BOCO ORTHOTIST
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:
1386866234
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 ALGONQUIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST SAND LAKE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12196-2000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-674-3361
Provider Business Mailing Address Fax Number:
518-674-8320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 ALGONQUIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST SAND LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12196-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-674-3361
Provider Business Practice Location Address Fax Number:
518-674-8320
Provider Enumeration Date:
05/02/2007

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: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01755577 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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