Provider Demographics
NPI:1073508206
Name:PELHAM, STEPHEN G (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:PELHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 E BAY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOLMES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34217-1997
Mailing Address - Country:US
Mailing Address - Phone:941-778-1007
Mailing Address - Fax:941-778-9256
Practice Address - Street 1:3909 E BAY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HOLMES BEACH
Practice Address - State:FL
Practice Address - Zip Code:34217-1997
Practice Address - Country:US
Practice Address - Phone:941-778-1007
Practice Address - Fax:941-778-9256
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065258000Medicaid
FL51125OtherBCBS
FL80124988OtherRAIL ROAD MEDICARE
FL80124988OtherRAIL ROAD MEDICARE
FLE11959Medicare UPIN
FL065258000Medicaid
FL51125YMedicare PIN