Provider Demographics
NPI:1659378131
Name:HERRMANN PELAGALLI, KRISTINE ALICE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ALICE
Last Name:HERRMANN PELAGALLI
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 1:303 E ROYALTON RD STE 204
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-4034
Mailing Address - Country:US
Mailing Address - Phone:440-717-2000
Mailing Address - Fax:440-717-2001
Practice Address - Street 1:303 E ROYALTON RD STE 204
Practice Address - Street 2:
Practice Address - City:BROADVIEW HTS
Practice Address - State:OH
Practice Address - Zip Code:44147-4034
Practice Address - Country:US
Practice Address - Phone:440-717-2000
Practice Address - Fax:440-717-2001
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074513174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0852142Medicare PIN
OHG75991Medicare UPIN