MEDICARE: JEFFREY ALLEN PEDERSON D.O.

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	208100000X	Physical Medicine & Rehabilitation Physician	3976	IA
2	208100000X	Physical Medicine & Rehabilitation Physician	5101016420	MI
3	208100000X	Physical Medicine & Rehabilitation Physician	DO-03976	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	164196	OTHER	IA	HEALTH ALLIANCE
2	500301	OTHER	IA	COVENTRY HEALTH CARE

General Provider Information

NPI Number	:	1285756486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY ALLEN PEDERSON D.O.

Provider Business Mailing Address
First Line	:	PO BOX 1475
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50305-1475
Country	:	US
Telephone Number	:	515-358-9461
Fax Number	:	515-358-9489

Provider Business Practice Location Address
First Line	:	12493 UNIVERSITY AVE STE 100
Second Line	:
City	:	CLIVE
State	:	IA
Zip	:	50325-8286
Country	:	US
Telephone Number	:	515-358-9461
Fax Number	:	515-358-9489

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

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	07/11/2024

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