Provider Demographics
NPI:1043591894
Name:MARIO F PELLEGRINO PEDS OT PC
Entity Type:Organization
Organization Name:MARIO F PELLEGRINO PEDS OT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:F
Authorized Official - Last Name:PELLEGRINO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:845-893-7550
Mailing Address - Street 1:4 CARLTON CT
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5830
Mailing Address - Country:US
Mailing Address - Phone:845-893-7550
Mailing Address - Fax:845-639-6749
Practice Address - Street 1:4 CARLTON CT
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-5830
Practice Address - Country:US
Practice Address - Phone:845-893-7550
Practice Address - Fax:845-639-6749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005347-1251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1Medicaid