Provider Demographics
NPI:1760431829
Name:PELLEGRINI, JAMES R (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:PELLEGRINI
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 1:400 GLEN COVE AVE
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-2100
Mailing Address - Country:US
Mailing Address - Phone:516-766-7556
Mailing Address - Fax:516-676-7534
Practice Address - Street 1:3301 AVENUE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2605
Practice Address - Country:US
Practice Address - Phone:718-338-7102
Practice Address - Fax:718-338-1280
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152142207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY152142OtherNEW YORK LICENSE
NY01850724Medicaid
NYC12132Medicare UPIN
NY83D581Medicare ID - Type Unspecified
NY01850724Medicaid