Basic Information
| Provider Information | |||||||||
| NPI: | 1083773089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEGRAM | ||||||||
| FirstName: | MELVIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6431 BAREBACK TER | ||||||||
| Address2: | |||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232344196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043197831 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5801 BREMO RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232261907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042877270 | ||||||||
| FaxNumber: | 8042850726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 0101223741 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 0101223741 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1083773089 | 05 | VA | MEDICAID | 1083773089 | 01 | VA | NPI | OTHER | C06778 | 01 | VA | GROUP PTAN | OTHER | P00685255 | 01 | VA | RR MEDICARE | OTHER |