MEDICARE: DR. GARY PEDNEAULT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	A48685	CA

General Provider Information

NPI Number	:	1003076845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY PEDNEAULT MD

Provider Business Mailing Address
First Line	:	PO BOX 2952
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90213-2952
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7257 W MANCHESTER AVE APT 3
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3517
Country	:	US
Telephone Number	:	310-410-8266
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	06/16/2008

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