Provider Demographics
NPI:1356353379
Name:CEDARHOLM, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CEDARHOLM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 MEDICAL PARK RD STE 303
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8525
Mailing Address - Country:US
Mailing Address - Phone:704-660-2617
Mailing Address - Fax:704-660-4107
Practice Address - Street 1:131 MEDICAL PARK RD STE 303
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8525
Practice Address - Country:US
Practice Address - Phone:704-660-2617
Practice Address - Fax:704-660-4107
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14610207RI0011X, 207RC0000X, 207RI0011X
NC33629207RI0011X, 207RI0011X, 207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00208334OtherRAILROAD MEDICARE
NC8921839Medicaid
NC1356353379Medicaid
SC146103Medicaid
NC21839OtherBCBS
NC21839OtherBCBS
NC2140591MMedicare PIN
SCD291048186Medicare PIN
SCAA51508186Medicare PIN