Basic Information
| Provider Information | |||||||||
| NPI: | 1023057726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELLIGRA | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8000 | ||||||||
| Address2: | DEPT 596 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662950041 | ||||||||
| FaxNumber: | 7083422517 | ||||||||
| Practice Location | |||||||||
| Address1: | 2164 HIGHWAY 35 | ||||||||
| Address2: | BLDG D-A | ||||||||
| City: | SEA GIRT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087501013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329740320 | ||||||||
| FaxNumber: | 7329741283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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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 | 207VG0400X | 25MA04651400 | NJ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1133209 | 05 | NJ | MEDICAID |