1578536504 NPI number — YVETTE-MARIE PELLEGRINO MD

Table of content: YVETTE-MARIE PELLEGRINO MD (NPI 1578536504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578536504 NPI number — YVETTE-MARIE PELLEGRINO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELLEGRINO
Provider First Name:
YVETTE-MARIE
Provider Middle Name:
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:
1578536504
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
955 RIBAUT RD
Provider Second Line Business Mailing Address:
BMAC CREDENTIALING
Provider Business Mailing Address City Name:
BEAUFORT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29902-5441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-522-7240
Provider Business Mailing Address Fax Number:
844-296-2253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BEAUFORT MEMORIAL LADY'S ISLAND INTERNAL MEDICINE
Provider Second Line Business Practice Location Address:
117 SEA ISLAND PARKWAY
Provider Business Practice Location Address City Name:
BEAUFORT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29907-1500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-522-7240
Provider Business Practice Location Address Fax Number:
843-522-7249
Provider Enumeration Date:
02/09/2006

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: 207QA0505X , with the licence number:  81574 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 200501189 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 81547 . This is a "SC STATE MD LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 5902403 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010724821 . This is a "TAX ID #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 815470 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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