Provider Demographics
NPI:1740251537
Name:PEDERSEN, NIELS FREDERIK (MD)
Entity type:Individual
Prefix:DR
First Name:NIELS
Middle Name:FREDERIK
Last Name:PEDERSEN
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:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:503-375-7451
Practice Address - Street 1:2020 CAPITOL ST NE
Practice Address - Street 2:SALEM CLINIC PC
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0644
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-375-7451
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1163207Q00000X
ORMD26800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141304903Medicaid
OR240514Medicaid
8A0594Medicare ID - Type Unspecified
ORR134993Medicare PIN
OR1228590005Medicare NSC
H27143Medicare UPIN