Provider Demographics
NPI:1477603660
Name:MARCELLO, PETER W (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:W
Last Name:MARCELLO
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:LAHEY CLINIC
Mailing Address - Street 2:41 MALL RD.
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-3760
Mailing Address - Fax:781-744-2945
Practice Address - Street 1:LAHEY CLINIC
Practice Address - Street 2:41 MALL RD.
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-3760
Practice Address - Fax:781-744-2945
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74572208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110050867AMedicaid
MAF14315Medicare UPIN
MAA2948901Medicare PIN