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General NPI Number Information
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NPI Number | 1184808065
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Entity Type | Organization
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Legal Business Name | WALTER J M PEDERSEN JR MD PC
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Dates
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Enumeration Date | 12/27/2007
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Last Update Date | 07/10/2012
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Provider Practice Location Address
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Address Line | SUNNY ISLE PROF BLDG SUITE 3F
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City | ST CROIX
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State | VI
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Zip | 00823-4423
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Country | US
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Telephone | 340-778-6110
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Fax | 340-778-2919
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Provider Business Mailing Address
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Address Line | PO BOX 7840
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City | CHRISTIANSTED
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State | VI
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Zip | 00823-7840
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Country | US
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Telephone | 340-778-6110
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Fax | 340-778-2919
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Authorized Official
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Title or Position | PRESIDENT
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Name | WALTER J M PEDERSEN JR.
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Credential | MD
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Telephone | 340-778-6110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 653
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License Number State | VI
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Taxonomy #2
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 653
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License Number State | VI
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