=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730159559
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW C PEDERZOLLI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2006
-----------------------------------------------------
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 | 330-352-2188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1059 EAST STATE ST
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-332-9991
-----------------------------------------------------
Fax | 330-332-2188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 35043732
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------