Provider Demographics
NPI:1730157058
Name:PEZZELLA, ANDREA M (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:PEZZELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 MIDLANDS CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3456
Mailing Address - Country:US
Mailing Address - Phone:803-457-7000
Mailing Address - Fax:803-457-7001
Practice Address - Street 1:115 MIDLANDS CT
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3456
Practice Address - Country:US
Practice Address - Phone:803-457-7000
Practice Address - Fax:803-457-7001
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29701207V00000X, 207VG0400X
MA204555207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1009200OtherCIGNA HEALTH PLAN
7099315OtherAETNA US HEALTHCARE
AA3715OtherHARVARD PILGRIM HEALTH CA
J22633OtherBLUE CARE ELECT
J22633OtherBLUE SHIELD INDEMNITY
0120961OtherMEDICAID WELFARE
0700410OtherEVERCARE
MA0120961Medicaid
042472266OtherONE HEALTH PLAN
A31235OtherMEDICARE B
042472266OtherTHREE RIVERS
37554OtherHEALTHY START
J22633OtherBLUE SHIELD HMO BLUE
042472266OtherTRICARE CHAMPUS
160049837OtherRAILROAD MEDICARE
45822OtherFALLON COMMUNITY HEALTH P
784225OtherMVP HEALTH CARE
042472266OtherPRIVATE HEALTHCARE SYSTEM
45822OtherFALLON COMMUNITY HEALTH P
H19207Medicare UPIN