Provider Demographics
NPI:1396723409
Name:PEDERSEN, JOHN C (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:270 S CLEVELAND MASSILLON RD STE C
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-6000
Mailing Address - Country:US
Mailing Address - Phone:330-443-0221
Mailing Address - Fax:330-303-1880
Practice Address - Street 1:270 S CLEVELAND MASSILLON RD STE C
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-6000
Practice Address - Country:US
Practice Address - Phone:330-443-0221
Practice Address - Fax:330-303-1880
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35--070058208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0435666Medicaid
OH1942892237OtherNPI2
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #
OH2167379Medicaid
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #