Provider Demographics
NPI:1265402242
Name:PELLEGRINI, JOANMARIE DIETZ (MD)
Entity type:Individual
Prefix:
First Name:JOANMARIE
Middle Name:DIETZ
Last Name:PELLEGRINI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8560
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:360 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3979
Practice Address - Country:US
Practice Address - Phone:207-907-3650
Practice Address - Fax:207-907-3660
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2022-02-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036-138577208600000X
MA81948208600000X, 2086S0127X
ME0154142086S0127X
MEMD154142086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery