Provider Demographics
NPI:1104828169
Name:PELLICONE, JOHN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:PELLICONE
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1901 1ST AVE RM 1B14
Mailing Address - Street 2:METROPOLITAN HOSPITAL CENTER-CHIEF MEDICAL OFFICER
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-7404
Mailing Address - Country:US
Mailing Address - Phone:212-423-8131
Mailing Address - Fax:212-423-8408
Practice Address - Street 1:1901 1ST AVE RM 1B14
Practice Address - Street 2:METROPOLITAN HOSPITAL CENTER-CHIEF MEDICAL OFFICER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-7404
Practice Address - Country:US
Practice Address - Phone:212-423-8131
Practice Address - Fax:212-423-8408
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY150985207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00964943Medicaid
NY00964943Medicaid
66D991Medicare ID - Type Unspecified