Basic Information
Provider Information | |||||||||
NPI: | 1417969064 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEDERSEN | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | T. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2917 | ||||||||
Address2: |   | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415022917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6062183500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 911 BYPASS RD | ||||||||
Address2: |   | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415011689 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6062183500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2006 | ||||||||
LastUpdateDate: | 06/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | MD-067177-L | PA | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 34198 | KY | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 001765945 | 01 | PA | HIGHMARK BLUE CROSS | OTHER | 1013753370001 | 05 | PA |   | MEDICAID |