Provider Demographics
NPI:1780655969
Name:PELLERITO, BENEDICT P (MD)
Entity Type:Individual
Prefix:
First Name:BENEDICT
Middle Name:P
Last Name:PELLERITO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BENEDETTO
Other - Middle Name:P
Other - Last Name:PELLERITO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:24715 LITTLE MACK AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3207
Mailing Address - Country:US
Mailing Address - Phone:586-779-7970
Mailing Address - Fax:586-779-7748
Practice Address - Street 1:24715 LITTLE MACK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3207
Practice Address - Country:US
Practice Address - Phone:586-779-7970
Practice Address - Fax:586-779-7748
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061624207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4327706Medicaid
MI4327706Medicaid