Healthcare Provider Details

I. General information

NPI: 1336707892
Provider Name (Legal Business Name): GERARD PELLEGRINI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E ERIE AVE
PHILADELPHIA PA
19134-1011
US

IV. Provider business mailing address

990 CORPORATE DR APT 514
WESTBURY NY
11590-6721
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-4067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number319163-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MB13047000
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberOS025130
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: