MEDICARE: WALTER J M PEDERSEN JR MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	653	VI
2	335E00000X	Prosthetic/Orthotic Supplier	653	VI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VI000011	OTHER	VI	TRICARE
2	0500138	OTHER	VI	HUMANA
3	170823200	OTHER	VI	USDL
4	1780671909	OTHER	VI	NPI
5	53699PE	OTHER	VI	TRIPLE-S
6	089045	OTHER	VI	BCBSVI
7	1184808065	OTHER	VI	NPI

General Provider Information

NPI Number	:	1184808065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALTER J M PEDERSEN JR MD PC

Provider Business Mailing Address
First Line	:	PO BOX 7840
Second Line	:
City	:	CHRISTIANSTED
State	:	VI
Zip	:	00823-7840
Country	:	US
Telephone Number	:	340-778-6110
Fax Number	:	340-778-2919

Provider Business Practice Location Address
First Line	:	SUNNY ISLE PROF BLDG
Second Line	:	SUITE 3F
City	:	ST CROIX
State	:	VI
Zip	:	00823-4423
Country	:	US
Telephone Number	:	340-778-6110
Fax Number	:	340-778-2919

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WALTER J M PEDERSEN JR.
Credential	:	MD
Telephone Number	:	340-778-6110

Provider Enumeration Date	:	12/27/2007
Last Update Date	:	07/10/2012

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