Provider Demographics
NPI:1083706162
Name:PEDERSEN, GLENN JAY (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:JAY
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-1103
Mailing Address - Country:US
Mailing Address - Phone:812-252-2225
Mailing Address - Fax:833-336-4142
Practice Address - Street 1:421 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:IN
Practice Address - Zip Code:47454
Practice Address - Country:US
Practice Address - Phone:812-252-2225
Practice Address - Fax:833-336-4142
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000852A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01682626OtherBLUE CROSS BLUE SHIELD
IL01682626OtherBLUE CROSS BLUE SHIELD