Healthcare Provider Details

I. General information

NPI: 1104046804
Provider Name (Legal Business Name): HOLLY JANE PEDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE A80
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

9500 EUCLID AVE A80
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-3052
  • Fax:
Mailing address:
  • Phone: 216-444-3052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-067285
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35067282
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: