Provider Demographics
NPI:1194908004
Name:PEDERSEN, PAMELA CAROL (MD,)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:CAROL
Last Name:PEDERSEN
Suffix:
Gender:F
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 132
Mailing Address - Street 2:1140 MAIN STREET
Mailing Address - City:FAIRFAX
Mailing Address - State:VT
Mailing Address - Zip Code:05454-0132
Mailing Address - Country:US
Mailing Address - Phone:516-232-7195
Mailing Address - Fax:
Practice Address - Street 1:48 LOWER NEWTON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1907
Practice Address - Country:US
Practice Address - Phone:802-524-4554
Practice Address - Fax:802-524-4501
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-13
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0009670207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1889Medicaid
VTCK1568Medicare PIN
VTVN0879Medicare PIN
VTD91818Medicare UPIN
VTVN188901Medicare PIN