Healthcare Provider Details

I. General information

NPI: 1336359280
Provider Name (Legal Business Name): KATHERINE MOSS PEDERSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N FORD RD
ZIONSVILLE IN
46077-1233
US

IV. Provider business mailing address

51 N FORD RD
ZIONSVILLE IN
46077-1233
US

V. Phone/Fax

Practice location:
  • Phone: 317-973-3333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01067517A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: