Healthcare Provider Details

I. General information

NPI: 1558354373
Provider Name (Legal Business Name): PELLEGRIN BROAD MORSE & MOY MDS & DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 E MAIN ST
LOS GATOS CA
95030-6903
US

IV. Provider business mailing address

143 E MAIN ST
LOS GATOS CA
95030-6903
US

V. Phone/Fax

Practice location:
  • Phone: 408-354-3920
  • Fax: 408-354-0782
Mailing address:
  • Phone: 408-354-3920
  • Fax: 408-354-0782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberG41377 G75242 A55016
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG41377 G67157 G75242
License Number StateCA

VIII. Authorized Official

Name: SUSAN HANSON
Title or Position: OFFICE/FINANCIAL MANAGER
Credential:
Phone: 408-354-4030