Healthcare Provider Details

I. General information

NPI: 1366536740
Provider Name (Legal Business Name): JOHN R PEDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE PMG PEDS HOSPITALISTS
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1063
  • Fax: 505-222-2695
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20030477
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: