Provider Demographics
NPI:1003892720
Name:PEDERSEN, PAUL CHRISTEN (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:CHRISTEN
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:606-528-8661
Practice Address - Street 1:602 KNOX ST
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-1304
Practice Address - Country:US
Practice Address - Phone:606-546-6027
Practice Address - Fax:606-546-2084
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31705208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64317050Medicaid
KYP01427263OtherRR MEDICARE
KYK054621Medicare PIN
KY0674002Medicare ID - Type Unspecified
KY64317050Medicaid
KYG15960Medicare UPIN