Provider Demographics
NPI:1497123418
Name:PEDERSEN FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:PEDERSEN FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-630-5506
Mailing Address - Street 1:2743 BETHPAGE CT
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-7741
Mailing Address - Country:US
Mailing Address - Phone:856-630-5506
Mailing Address - Fax:
Practice Address - Street 1:1450 E CHESTNUT AVE
Practice Address - Street 2:BUILDING 3, SUITE D
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08361-8467
Practice Address - Country:US
Practice Address - Phone:856-692-0050
Practice Address - Fax:856-692-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09405100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty