=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184697294
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREW C PEDERZOLLI MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2006
-----------------------------------------------------
Last Update Date | 09/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1059 E STATE ST
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-332-9991
-----------------------------------------------------
Fax | 330-332-2188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1059 E STATE ST
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-332-9991
-----------------------------------------------------
Fax | 330-332-2188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDREW C PEDERZOLLI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 330-332-9991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------