Provider Demographics
NPI:1134237753
Name:PEDERSEN, CHRISTINE M (MSPT)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:M
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6107
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61125
Mailing Address - Country:US
Mailing Address - Phone:815-397-4142
Mailing Address - Fax:815-397-4144
Practice Address - Street 1:6905 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-397-4142
Practice Address - Fax:815-397-4144
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012627208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00426232OtherMEDICARE RAILROAD
IL5378720001Medicare NSC
ILP00426232OtherMEDICARE RAILROAD