Provider Demographics
NPI:1912919523
Name:PELICAN, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:PELICAN
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 31367
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-0367
Mailing Address - Country:US
Mailing Address - Phone:314-845-0766
Mailing Address - Fax:314-845-0766
Practice Address - Street 1:2428 WOODSON RD
Practice Address - Street 2:
Practice Address - City:OVERLAND
Practice Address - State:MO
Practice Address - Zip Code:63114-5423
Practice Address - Country:US
Practice Address - Phone:314-241-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33873174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPE200214906Medicaid
MOPE200214906Medicaid
MOA11065Medicare UPIN