Basic Information
| Provider Information | |||||||||
| NPI: | 1629037627 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERGAMENT | ||||||||
| FirstName: | STUART | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CENTENNIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785351110 | ||||||||
| FaxNumber: | 9785352907 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 CENTENNIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785351110 | ||||||||
| FaxNumber: | 9785352907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 12/26/2012 | ||||||||
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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 | 208000000X | 79121 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3132544 | 05 | MA | MEDICAID |