Provider Demographics
NPI:1285922146
Name:PEDERSEN, BRIAN (PT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1209
Mailing Address - Country:US
Mailing Address - Phone:847-673-5073
Mailing Address - Fax:847-673-2475
Practice Address - Street 1:4607 GOLF RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1209
Practice Address - Country:US
Practice Address - Phone:847-673-5073
Practice Address - Fax:847-673-2475
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-018515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist