Basic Information
| Provider Information | |||||||||
| NPI: | 1003892720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDERSEN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | CHRISTEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1325 | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407021325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065268131 | ||||||||
| FaxNumber: | 6065288661 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 KNOX ST | ||||||||
| Address2: | |||||||||
| City: | BARBOURVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409061304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065466027 | ||||||||
| FaxNumber: | 6065462084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 31705 | KY | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 64317050 | 05 | KY | MEDICAID | P01427263 | 01 | KY | RR MEDICARE | OTHER |