Provider Demographics
NPI:1518904416
Name:PRONOVOST, PETER JOHN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:PRONOVOST
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 64382
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4382
Mailing Address - Country:US
Mailing Address - Phone:410-933-5474
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-6353
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD46479207LC0200X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0162621300Medicaid
MD227VMedicare ID - Type Unspecified
MDF92104Medicare UPIN
MDKR78JHMedicare ID - Type Unspecified
MDKR79JHMedicare ID - Type Unspecified
MD709TMedicare ID - Type Unspecified