Active NPI
Tedijo Pederson, ATC
- Athletic Trainer
- Butte, MT
National Provider Identifier
1205453552
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- ATR-LAT-LIC-2508
- Practice address
- 400 S Clark St
Butte, MT 59701-2328 - Phone
- (406) 723-2500
- NPI assigned
- Jul 2, 2020
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | |||
| Athletic Trainer | 2255A2300X | ATR-LAT-LIC-2508 | MT | Primary |
Addresses
Primary practice location
400 S Clark St
Butte, MT 59701-2328
Mailing address
2034 Colt Dr
P.O. Box 55
Victor, MT 59875
Phone (406) 930-2150
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ATR-LAT-LIC-2508 | MT | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1593648000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1657238400000",
"number": "1205453552",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2034 COLT DR",
"address_2": "P.O. BOX 55",
"city": "VICTOR",
"state": "MT",
"postal_code": "59875",
"telephone_number": "406-930-2150"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "400 S CLARK ST",
"city": "BUTTE",
"state": "MT",
"postal_code": "597012328",
"telephone_number": "406-723-2500"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PEDERSON",
"first_name": "TEDIJO",
"credential": "ATC",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2020-07-02",
"last_updated": "2022-07-08",
"certification_date": "2022-06-09",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": false
},
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "MT",
"license": "ATR-LAT-LIC-2508",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Butte, MT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.