Basic Information
| Provider Information | |||||||||
| NPI: | 1538170691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELLEGRINO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26125 | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443196125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304930840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6651 FRANK AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304989865 | ||||||||
| FaxNumber: | 3304989869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 11/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 35050212 | OH | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 341750133 | 01 | OH | SUMMACARE | OTHER | 341898905030 | 01 | OH | CARESOURCE | OTHER | 250011247 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000141768 | 01 | OH | ANTHEM | OTHER | 341898905B | 01 | OH | AULTCARE | OTHER | 0715739 | 05 | OH | MEDICAID |