1083816912 NPI number — MARRISSA C PELLETIER MD

Table of content: MARRISSA C PELLETIER MD (NPI 1083816912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083816912 NPI number — MARRISSA C PELLETIER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELLETIER
Provider First Name:
MARRISSA
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083816912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 647
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOPE MILLS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28348-0647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-483-7337
Provider Business Mailing Address Fax Number:
910-483-0648

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
427 HARRISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28734-2580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-524-7337
Provider Business Practice Location Address Fax Number:
828-369-1340
Provider Enumeration Date:
06/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  243167 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 2014-00372 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1083816912 . This is a "HUMANA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1083816912 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9208288 . This is a "CIGNA GREATWEST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 984960 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003145877A . This is a "PEACHCARE 4 KIDS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 4302375 . This is a "COVENTRY NATIONAL - COVENTRY PPO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: FH1101660 . This is a "FIRST CAROLINA CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1083816912 . This is a "HEALTHSMART" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 02900278 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12669052 . This is a "PHCS-MULTIPLAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1461884 . This is a "WELLPATH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 186BW . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 276479 . This is a "MEDCOST, LLC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2379703 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2889619 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 003145877A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1083816912 . This is a "HEALTHNET FEDERAL SERVICES" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1083816912 . This is a "DOCTORS DIRECT" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1461884 . This is a "COVENTRY OF THE CAROLINAS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 9102458 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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