Basic Information
Provider Information
NPI: 1003807058
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PEDERSEN
FirstName: ROBERT
MiddleName: CHRISTIAN
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1 JARRETT WHITE ROAD
Address2: TRIPLER ARMY MEDICAL CENTER ATTN: MCHK-QS
City: TRIPLER AMC
State: HI
PostalCode: 968595000
CountryCode: US
TelephoneNumber: 8084332460
FaxNumber: 8084331558
Practice Location
Address1: 1 JARRETT WHITE ROAD
Address2: TRIPLER ARMY MEDICAL CENTER
City: TRIPLER AMC
State: HI
PostalCode: 968595000
CountryCode: US
TelephoneNumber: 8084332460
FaxNumber: 8084331558
Other Information
ProviderEnumerationDate: 10/31/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2084N0402X25994WAY Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology

No ID Information.


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