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NPI Code Detail

MEDICARE: DR. JASEN THOMAS PEDERSEN DPM

MEDICARE: DR. JASEN THOMAS PEDERSEN DPM
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
1213E00000XPodiatrist243971KY
2213ES0103XFoot & Ankle Surgery Podiatrist243971KY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2000000866560OTHERKYANTHEM

General Provider Information

NPI Number : 1114182326
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JASEN THOMAS PEDERSEN DPM
Provider Business Mailing Address
First Line : 6400 WESTWIND WAY
Second Line : SUITE B
City : CRESTWOOD
State : KY
Zip : 40014-6773
Country : US
Telephone Number : 502-276-9999
Fax Number : 502-276-9999
Provider Business Practice Location Address
First Line : 6400 WESTWIND WAY
Second Line : SUITE B
City : CRESTWOOD
State : KY
Zip : 40014-6773
Country : US
Telephone Number : 502-276-9999
Fax Number : 502-276-9999
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/28/2008
Last Update Date : 04/27/2020

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