Active NPI
Mark Pederson, LP
- Psychologist
- Buffalo, MN
National Provider Identifier
1801994843
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- LP2544
- Practice address
- 102 Marty Dr
Buffalo, MN 55313 - Phone
- (763) 682-5420
- Fax
- (763) 682-5803
- NPI assigned
- Sep 21, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | LP2544 | MN | Primary |
Addresses
Primary practice location
102 Marty Dr
Buffalo, MN 55313
Mailing address
102 Marty Dr
Buffalo, MN 55313
Phone (763) 682-5420
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 110563 | Other | MN | UCARE |
| HP18919 | Other | MN | HEALTHPARTNERS |
| 62-20079 | Other | MN | MEDICA |
| 67D66PE | Other | MN | BLUE CROSS BLUE SHIELD |
| 1000260 | Other | MN | PREFERRED ONE |
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 |
|---|---|---|---|
| LP2544 | MN | MD | Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Family Counseling Center Inc | Psychologist | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Psychologist
- Buffalo, MN
- NPI 1750483269
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158796800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1801994843",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "102 MARTY DR",
"city": "BUFFALO",
"state": "MN",
"postal_code": "55313",
"telephone_number": "763-682-5420",
"fax_number": "763-682-5803"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "102 MARTY DR",
"city": "BUFFALO",
"state": "MN",
"postal_code": "55313",
"telephone_number": "763-682-5420",
"fax_number": "763-682-5803"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PEDERSON",
"first_name": "MARK",
"credential": "LP",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-09-21",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "MN",
"license": "LP2544",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UCARE",
"identifier": "110563",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "HEALTHPARTNERS",
"identifier": "HP18919",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICA",
"identifier": "62-20079",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "67D66PE",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PREFERRED ONE",
"identifier": "1000260",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Buffalo, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.