Basic Information
| Provider Information | |||||||||
| NPI: | 1235734021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDERSEN | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | BJORN | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 205 BURLINGTON RD | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017301406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817615089 | ||||||||
| FaxNumber: | 7812757207 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 BURLINGTON RD | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017301406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817615089 | ||||||||
| FaxNumber: | 7812757207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2020 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 042611055 | 01 | MA | TAX ID | OTHER | 1303287 | 01 | MA | MBHP | OTHER | 0000023532 | 01 | MA | BMC | OTHER | M18633 | 01 | MA | BCBS | OTHER | 1004745 | 01 | MA | NHP | OTHER | 1004745 | 01 | MA | FALLON | OTHER | 99618201 | 01 | MA | NETWORK HEALTH | OTHER |