Provider Demographics
NPI:1538170691
Name:PELLEGRINO, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:PELLEGRINO
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 26125
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-6125
Mailing Address - Country:US
Mailing Address - Phone:330-493-0840
Mailing Address - Fax:
Practice Address - Street 1:6651 FRANK AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720
Practice Address - Country:US
Practice Address - Phone:330-498-9865
Practice Address - Fax:330-498-9869
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050212208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341750133OtherSUMMACARE
OH341898905030OtherCARESOURCE
OH250011247OtherRAILROAD MEDICARE
OH000000141768OtherANTHEM
OH341898905BOtherAULTCARE
OH0715739Medicaid
OH0715739Medicaid
OH0889401Medicare PIN
OH0889404Medicare PIN
OH000000141768OtherANTHEM