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

Table of content: JEAN MARIE RASIMOWICZ NP-C (NPI 1932411030)

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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