Provider Demographics
NPI:1245211911
Name:PELLEGRINO, ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:PELLEGRINO
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:PO BOX 11314
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4004
Mailing Address - Country:US
Mailing Address - Phone:757-547-0508
Mailing Address - Fax:757-547-8963
Practice Address - Street 1:300 MEDICAL PKWY STE 314
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4985
Practice Address - Country:US
Practice Address - Phone:757-547-0508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25352207L00000X
NC02618207LP2900X
VA0101265619207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ39174802Medicaid
F70064Medicare UPIN
AZ39174802Medicaid