Provider Demographics
NPI:1205821261
Name:PELLEGRINI, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:PELLEGRINI
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 1:255 MAIN ST
Mailing Address - Street 2:P.O. BOX 983
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-7315
Mailing Address - Country:US
Mailing Address - Phone:606-633-2261
Mailing Address - Fax:606-633-9643
Practice Address - Street 1:214 HOSPITAL RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7627
Practice Address - Country:US
Practice Address - Phone:606-633-2255
Practice Address - Fax:606-633-3814
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19935208600000X
VA0101035778208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007358229Medicaid
KY64199359Medicaid
KY1446301Medicare PIN
KY64199359Medicaid
B05286Medicare UPIN