Provider Demographics
NPI:1053403675
Name:PEDERSEN, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2101
Mailing Address - Country:US
Mailing Address - Phone:309-664-3120
Mailing Address - Fax:309-663-5742
Practice Address - Street 1:1701 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2101
Practice Address - Country:US
Practice Address - Phone:309-664-3120
Practice Address - Fax:309-663-5742
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-059949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059949Medicaid
D14321Medicare UPIN
ILCA2264Medicare ID - Type UnspecifiedRR GROUP #
ILL32786Medicare ID - Type UnspecifiedINDIVIDUAL #
IL110090455Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL036059949Medicaid