Healthcare Provider Details

I. General information

NPI: 1396723409
Provider Name (Legal Business Name): JOHN C PEDERSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 S CLEVELAND MASSILLON RD STE C
FAIRLAWN OH
44333-6000
US

IV. Provider business mailing address

270 S CLEVELAND MASSILLON RD STE C
FAIRLAWN OH
44333-6000
US

V. Phone/Fax

Practice location:
  • Phone: 330-443-0221
  • Fax: 330-303-1880
Mailing address:
  • Phone: 330-443-0221
  • Fax: 330-303-1880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35--070058
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: