Provider Demographics
NPI:1184808065
Name:WALTER J M PEDERSEN JR MD PC
Entity type:Organization
Organization Name:WALTER J M PEDERSEN JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:J M
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:340-778-6110
Mailing Address - Street 1:PO BOX 7840
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00823-7840
Mailing Address - Country:US
Mailing Address - Phone:340-778-6110
Mailing Address - Fax:340-778-2919
Practice Address - Street 1:SUNNY ISLE PROF BLDG
Practice Address - Street 2:SUITE 3F
Practice Address - City:ST CROIX
Practice Address - State:VI
Practice Address - Zip Code:00823-4423
Practice Address - Country:US
Practice Address - Phone:340-778-6110
Practice Address - Fax:340-778-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI653207X00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VIVI000011OtherTRICARE
VI0500138OtherHUMANA
VI170823200OtherUSDL
VI1780671909OtherNPI
VI53699PEOtherTRIPLE-S
VI089045OtherBCBSVI
VI1184808065OtherNPI
VI1184808065OtherNPI
VI1184808065OtherNPI
VI4828560001Medicare NSC
VI53699PEOtherTRIPLE-S