Provider Demographics
NPI:1083690622
Name:PEDERSON, LEE CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:CARL
Last Name:PEDERSON
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 33369
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28233-3369
Mailing Address - Country:US
Mailing Address - Phone:704-916-2108
Mailing Address - Fax:704-365-2073
Practice Address - Street 1:2001 VAIL AVE STE 320
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1222
Practice Address - Country:US
Practice Address - Phone:704-364-8100
Practice Address - Fax:704-365-2073
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2023-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300515208600000X
NC0300515208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891344Medicaid
NC2014632-AMedicare ID - Type UnspecifiedCTS MEDICARE NUMBER
G18638Medicare UPIN
NCG18602Medicare UPIN
NC2014632Medicare ID - Type UnspecifiedCSG MEDICARE NUMBER
NC891344Medicaid