Basic Information
| Provider Information | |||||||||
| NPI: | 1770570186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANTELIDIS | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 449 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 799 FARSON ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | BELPRE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457141044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404233082 | ||||||||
| FaxNumber: | 7404233083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35086212 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 21925 | WV | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | MD425120 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 21925 | WV | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 35086212 | OH | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3810001748 | 05 | WV | MEDICAID | 2588605 | 05 | OH | MEDICAID |