Basic Information
| Provider Information | |||||||||
| NPI: | 1316997695 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDERSEN | ||||||||
| FirstName: | KARI | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KIRK | ||||||||
| OtherFirstName: | KARI | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10000 BAY PINES BLVD | ||||||||
| Address2: | MAIL STOP 117 | ||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337448200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | 7273989440 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 BAY PINES BLVD | ||||||||
| Address2: | 115 | ||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337448200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | ME81027 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 259657100 | 05 | FL | MEDICAID |