Glenn Jay Pedersen, D.C.
Individual provider Active NPI Chiropractor · Paoli, IN
NPI 1083706162 · NPPES record last updated May 21, 2025
Key facts
- NPI
- 1083706162
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Chiropractor 111N00000X
- License
- 08000852A (IN)
- Practice address
- 650 N Gospel St Ste 4
Paoli, IN 47454-1482 - Phone
- (812) 252-2225
- Fax
- (833) 336-4142
- NPI assigned
- Sep 28, 2006
- Sex
- Male
- Sole proprietor
- Yes
Medicare Care Compare profile
- Specialty
- Chiropractic
- Education
- National College of Chiropractic, 1982
- Medicare assignment
- May accept Medicare assignment
Practice addresses (Care Compare)
421 SW 1St St
Paoli, IN 47454-1103
650 N Gospel St
Paoli, IN 47454-1483
Phone (812) 252-2225
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20190103001937 | IN | Practitioner - Chiropractic | 8921005513 | Practice locations: Paoli, IN |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Chiropractor |
111N00000X | 08000852A | IN | Yes |
Addresses
Primary practice location
650 N Gospel St Ste 4
Paoli, IN 47454-1482
Mailing address
650 N Gospel St
Paoli, IN 47454-1483
Phone (812) 252-2225
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 01682626 | Other | IL | BLUE CROSS BLUE SHIELD |
Other providers in Paoli, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 21, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.