Provider Demographics
NPI:1053318527
Name:PELEROSSI, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PELEROSSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 29TH AVE N
Mailing Address - Street 2:STE 202
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 29TH AVE N
Practice Address - Street 2:STE 202
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1401
Practice Address - Country:US
Practice Address - Phone:615-327-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN022096174400000X
TN22096207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009901215Medicaid
TN3018648OtherBCBS PROVIDER NUMBER
TN3067066Medicaid
KY64911654Medicaid
TNE76352Medicare UPIN
KY64911654Medicaid