Basic Information
| Provider Information | |||||||||
| NPI: | 1962767855 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDRICK | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 335 GLESSNER AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195202495 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6905 HOSPITAL DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430169600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149230300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2012 | ||||||||
| LastUpdateDate: | 10/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-127818 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0122505 | 05 | OH | MEDICAID |