1730172479 NPI number — DR. FRANCIS B PELLEGRINO MD

Table of content: DR. FRANCIS B PELLEGRINO MD (NPI 1730172479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730172479 NPI number — DR. FRANCIS B PELLEGRINO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELLEGRINO
Provider First Name:
FRANCIS
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1730172479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18550 US HIGHWAY 441
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
MOUNT DORA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32757-6751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-992-6658
Provider Business Mailing Address Fax Number:
352-503-0663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1745 E HWY 50
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CLERMONT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34711-5037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-394-8060
Provider Business Practice Location Address Fax Number:
352-708-6420
Provider Enumeration Date:
08/29/2005

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: 207Q00000X , with the licence number:  ME55766 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 593516436 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 054022600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09743 . This is a "BCBS FLORIDA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00390401 . This is a "RR PALMETTO GBA" identifier . This identifiers is of the category "OTHER".




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