Provider Demographics
NPI:1972689578
Name:ANDREW C PEDERZOLLI MD INC
Entity Type:Organization
Organization Name:ANDREW C PEDERZOLLI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEDERZOLLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-821-0314
Mailing Address - Street 1:32 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-2647
Mailing Address - Country:US
Mailing Address - Phone:330-821-0314
Mailing Address - Fax:330-821-2293
Practice Address - Street 1:32 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-2647
Practice Address - Country:US
Practice Address - Phone:330-821-0314
Practice Address - Fax:330-821-2293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0173771Medicaid
OH0173771Medicaid