Provider Demographics
NPI:1336165844
Name:PESCATELLO, MICHAEL CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:PESCATELLO
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 1:15 RAY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4814
Mailing Address - Country:US
Mailing Address - Phone:617-877-0665
Mailing Address - Fax:
Practice Address - Street 1:1003 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02019-1826
Practice Address - Country:US
Practice Address - Phone:508-883-0600
Practice Address - Fax:508-883-5990
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223185207R00000X
RIMD11642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2094967Medicaid
A38017Medicare ID - Type Unspecified
MA2094967Medicaid