Provider Demographics
NPI:1225094402
Name:PELLICANO, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:PELLICANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BELTON LN
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31411-1632
Mailing Address - Country:US
Mailing Address - Phone:912-598-0501
Mailing Address - Fax:
Practice Address - Street 1:1915 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-5027
Practice Address - Country:US
Practice Address - Phone:912-356-2011
Practice Address - Fax:912-351-3538
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0373302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA037330OtherLICENSE
GA26BDJGRMedicare ID - Type Unspecified
GA037330OtherLICENSE