Provider Demographics
NPI:1821069832
Name:PELLISH, LARRY J (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:J
Last Name:PELLISH
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 1:777 NORTH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4147
Mailing Address - Country:US
Mailing Address - Phone:413-499-8590
Mailing Address - Fax:413-499-6410
Practice Address - Street 1:777 NORTH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4147
Practice Address - Country:US
Practice Address - Phone:413-499-8590
Practice Address - Fax:413-499-6410
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA40795174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00536205Medicaid
NY10034390OtherCDPHP
MA15329OtherHEALTH NEW ENGLAND
MA2056186Medicaid
NY365677OtherMVP
MAA66253OtherHARVARD PILGRIM HEALTHCAR
MA040795OtherTUFTS HEALTHPLAN
MAI22244OtherBCBSMA
NY365677OtherMVP
I22244Medicare ID - Type Unspecified