Provider Demographics
NPI:1104007442
Name:JAN PEDERSEN
Entity Type:Organization
Organization Name:JAN PEDERSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:ORTHOTIST
Authorized Official - Phone:518-674-3361
Mailing Address - Street 1:23 ALGONQUIN RD
Mailing Address - Street 2:
Mailing Address - City:WEST SAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12196-2000
Mailing Address - Country:US
Mailing Address - Phone:518-674-3361
Mailing Address - Fax:518-674-8320
Practice Address - Street 1:23 ALGONQUIN RD
Practice Address - Street 2:
Practice Address - City:WEST SAND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12196-2000
Practice Address - Country:US
Practice Address - Phone:518-674-3361
Practice Address - Fax:518-674-8320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01755577Medicaid
NY4483480001Medicare NSC