Basic Information
| Provider Information | |||||||||
| NPI: | 1619924354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELLEGRINO | ||||||||
| FirstName: | LOUIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 IRVING AVE | ||||||||
| Address2: | CROUSE POB | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154646395 | ||||||||
| FaxNumber: | 3154647564 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 IRVING AVE | ||||||||
| Address2: | CROUSE POB | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154646395 | ||||||||
| FaxNumber: | 3154647564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 08/27/2013 | ||||||||
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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 | 2080P0008X | 185838 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 01404291 | 05 | NY | MEDICAID |