Provider Demographics
NPI:1578536504
Name:PELLEGRINO, YVETTE-MARIE (MD)
Entity Type:Individual
Prefix:
First Name:YVETTE-MARIE
Middle Name:
Last Name:PELLEGRINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 RIBAUT RD
Mailing Address - Street 2:BMAC CREDENTIALING
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5441
Mailing Address - Country:US
Mailing Address - Phone:843-522-7240
Mailing Address - Fax:844-296-2253
Practice Address - Street 1:BEAUFORT MEMORIAL LADY'S ISLAND INTERNAL MEDICINE
Practice Address - Street 2:117 SEA ISLAND PARKWAY
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907-1500
Practice Address - Country:US
Practice Address - Phone:843-522-7240
Practice Address - Fax:843-522-7249
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC81574207QA0505X
NC200501189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC81547OtherSC STATE MD LICENSE
NC5902403Medicaid
NC010724821OtherTAX ID #
SC815470Medicaid
SC815470Medicaid