Provider Demographics
NPI:1346260056
Name:PERGOLIZZI, JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:PERGOLIZZI
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 1:7288 MOSS CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3784
Mailing Address - Country:US
Mailing Address - Phone:315-453-7289
Mailing Address - Fax:
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-5861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152144-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00933748Medicaid
NY729OtherTOTAL CARE
NY729156OtherMVP
NY0082716OtherGHI
NY040426015099OtherFIDELIS
NY4700004OtherUNITED MCD
NY10500339OtherBLUE SHIELD