=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043531247
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA MARIE PELLEGRINO D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2010
-----------------------------------------------------
Last Update Date | 12/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23203 COLUMBUS RD STE I
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-303-4450
-----------------------------------------------------
Fax | 609-303-4451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23203 COLUMBUS RD STE I
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08022-1985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-303-4450
-----------------------------------------------------
Fax | 609-303-4451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MB09161600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------