Provider Demographics
NPI:1770570186
Name:PANTELIDIS, PETER GEORGE (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:GEORGE
Last Name:PANTELIDIS
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 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:799 FARSON ST STE 210
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-1044
Practice Address - Country:US
Practice Address - Phone:740-423-3082
Practice Address - Fax:740-423-3083
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425120207L00000X
WV21925208VP0014X, 208VP0014X
OH35086212208VP0014X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001748Medicaid
OH2588605Medicaid
OHP01401801OtherRAILROAD MEDICARE - MHCPI
OHH383121Medicare PIN
WV3810001748Medicaid
OHPA4220571Medicare PIN
I20359Medicare UPIN
OHH383120Medicare PIN