Provider Demographics
NPI:1851359442
Name:PRENDERGAST, PETER G (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:PRENDERGAST
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-474-3444
Mailing Address - Fax:336-474-8111
Practice Address - Street 1:207 OLD LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3428
Practice Address - Country:US
Practice Address - Phone:336-474-3444
Practice Address - Fax:336-474-8111
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162805207R00000X
NC2007-01027207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00418365Medicaid
NC5907559Medicaid
NC5907559Medicaid
NY00418365Medicaid
NY51804BMedicare ID - Type Unspecified