Basic Information
| Provider Information | |||||||||
| NPI: | 1245261569 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERETIN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | PALUMBO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10203 SADDLEBROOKE LN | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217401578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048868998 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11110 MEDICAL CAMPUS RD | ||||||||
| Address2: | SUITE 248 | ||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217426700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2403139800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 21492 | WV | N | Other Service Providers | Specialist | 207L00000X | MD448290 | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1804751000 | 05 | WV | MEDICAID |