Provider Demographics
NPI:1962629105
Name:PELLISH, RANDALL
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:PELLISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LAHEY HOSPITAL AND MEDICAL CENTER
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8740
Mailing Address - Fax:781-744-5276
Practice Address - Street 1:LAHEY HOSPITAL AND MEDICAL CENTER
Practice Address - Street 2:41 MALL ROAD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805
Practice Address - Country:US
Practice Address - Phone:781-744-8740
Practice Address - Fax:781-744-5276
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP00382207RG0100X
MA234728207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2152053Medicaid
MA000601801Medicare PIN