Provider Demographics
NPI:1891802286
Name:PELEGRIN, JODI ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:ANN
Last Name:PELEGRIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:ANN
Other - Last Name:PELEGRIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:518 LUCINDA AVE
Mailing Address - Street 2:NIU HEALTH SERVICES
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115
Mailing Address - Country:US
Mailing Address - Phone:815-753-1311
Mailing Address - Fax:
Practice Address - Street 1:518 LUCINDA AVE
Practice Address - Street 2:NIU HEALTH SERVICES
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115
Practice Address - Country:US
Practice Address - Phone:815-753-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-119124207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04515143OtherBCBS#
IL0727500001Medicare NSC
ILK45009Medicare PIN
G85645Medicare UPIN
ILK45010Medicare PIN