Provider Demographics
NPI:1386641850
Name:ERCOLINO, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:ERCOLINO
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 1:3004 BELSPRING LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5229
Mailing Address - Country:US
Mailing Address - Phone:919-782-2783
Mailing Address - Fax:
Practice Address - Street 1:1655 WAKE DRIVE
Practice Address - Street 2:STE 101
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587
Practice Address - Country:US
Practice Address - Phone:919-556-4779
Practice Address - Fax:919-556-5277
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126J5Medicaid
NCH14118Medicare UPIN