Provider Demographics
NPI:1609835800
Name:PELLEGRINO, GEORGE MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MICHAEL
Last Name:PELLEGRINO
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 1:200 GLENN ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2436
Mailing Address - Country:US
Mailing Address - Phone:301-724-0061
Mailing Address - Fax:
Practice Address - Street 1:200 GLENN ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2436
Practice Address - Country:US
Practice Address - Phone:301-724-0061
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDVADOOMedicare UPIN