Provider Demographics
NPI:1285836445
Name:PEREGRIM, DORINE
Entity Type:Individual
Prefix:
First Name:DORINE
Middle Name:
Last Name:PEREGRIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 STATE ROUTE 86
Mailing Address - Street 2:P.O. BOX 1380
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-5644
Mailing Address - Country:US
Mailing Address - Phone:518-897-2317
Mailing Address - Fax:518-897-2423
Practice Address - Street 1:2233 STATE ROUTE 86
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5644
Practice Address - Country:US
Practice Address - Phone:518-897-2317
Practice Address - Fax:518-897-2423
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00363213Medicaid
NY012312OtherLICENSE #
NY012312OtherLICENSE #
NY33U079Medicare ID - Type UnspecifiedHOSPITAL MCR SWING BED #