MEDICARE: MARY M PELLEGRINO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA2251	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912965856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY M PELLEGRINO

Provider Business Mailing Address
First Line	:	3215 CAPITAL MEDICAL BLVD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-4413
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3215 CAPITAL MEDICAL BLVD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-4413
Country	:	US
Telephone Number	:	850-878-0609
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARY PELLEGRINO
Credential	:
Telephone Number	:	850-878-0609

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	04/12/2012

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Directions to “MARY M PELLEGRINO ” Practice Location

Language	Start Address	Practice Location

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