Healthcare Provider Details

I. General information

NPI: 1790994283
Provider Name (Legal Business Name): BLAKE EDWIN PEDERSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

6034 MARDEL AVE
SAINT LOUIS MO
63109-1350
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-6978
  • Fax:
Mailing address:
  • Phone: 314-832-9583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2007001632
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: