Provider Demographics
NPI:1659578417
Name:PEDERSON, BARRY J (DPT CSCS)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:J
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:DPT CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 GOLF COURSE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3555
Mailing Address - Country:US
Mailing Address - Phone:218-326-3300
Mailing Address - Fax:218-326-3400
Practice Address - Street 1:1542 GOLF COURSE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3555
Practice Address - Country:US
Practice Address - Phone:218-326-3300
Practice Address - Fax:218-326-3400
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10875-024225100000X
MN7925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36139200Medicaid