Provider Demographics
NPI:1912988627
Name:PELLEGRINO, RICHARD G (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:PELLEGRINO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MERCY LN
Mailing Address - Street 2:SUITE 505
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6442
Mailing Address - Country:US
Mailing Address - Phone:501-623-0280
Mailing Address - Fax:501-623-2405
Practice Address - Street 1:1 MERCY LN
Practice Address - Street 2:SUITE 505
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6442
Practice Address - Country:US
Practice Address - Phone:501-623-0280
Practice Address - Fax:501-623-2405
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN76492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE10471Medicare UPIN
AR51064Medicare ID - Type Unspecified