MEDICARE: DR. WALTER JM PEDERSEN JR. MD

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	174400000X	Specialist	653	VI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V1000011	OTHER	VI	TRICARE
2	1780671909	OTHER	VI	NPI
3	53699PE	OTHER	VI	TRIPLE S
4	089045	OTHER	VI	BLUE CROSS BLUE SHIELD VI
5	0500138	OTHER	VI	HUMANA

General Provider Information

NPI Number	:	1780671909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER JM PEDERSEN JR. MD

Provider Business Mailing Address
First Line	:	PO BOX 7840
Second Line	:	SUNNY ISLE PROFESSIONAL BLDG, STE 3
City	:	ST CROIX
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 PROFESSIONAL BUILDING
Second Line	:	SUITE 3-F
City	:	ST. CROIX
State	:	VI
Zip	:	00820-4423
Country	:	US
Telephone Number	:	340-778-6110
Fax Number	:	340-778-2919

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	12/11/2007

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