Provider Demographics
NPI:1932179983
Name:PEDERSEN, ROBERT ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
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 1:1505 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2500
Mailing Address - Country:US
Mailing Address - Phone:706-275-6121
Mailing Address - Fax:
Practice Address - Street 1:1505 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2500
Practice Address - Country:US
Practice Address - Phone:706-275-6121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021783174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA406133349OtherMEDICARE RAILROAD
GA000200307DMedicaid
GAD30432Medicare UPIN