Provider Demographics
NPI:1568991446
Name:PEDERSON, CALLIE (DO)
Entity Type:Individual
Prefix:DR
First Name:CALLIE
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 DOOLITTLE DRIVE
Mailing Address - Street 2:2900 DOOLITTLE DRIVE
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-9144
Mailing Address - Country:US
Mailing Address - Phone:605-385-3111
Mailing Address - Fax:
Practice Address - Street 1:28TH MEDICAL GROUP
Practice Address - Street 2:2900 DOOLITLE DRIVE
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4821
Practice Address - Country:US
Practice Address - Phone:605-385-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
VA0102205476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider