Provider Demographics
NPI:1194712505
Name:PETERLIN, MELINDA H (MD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:H
Last Name:PETERLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:HOUGH
Other - Last Name:PETERLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7000 WELLNESS WAY STE 7230
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2286
Mailing Address - Country:US
Mailing Address - Phone:912-634-2795
Mailing Address - Fax:912-638-5636
Practice Address - Street 1:7000 WELLNESS WAY STE 7230
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2286
Practice Address - Country:US
Practice Address - Phone:912-634-2795
Practice Address - Fax:912-638-5636
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44728 020208000000X
GA072916208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34231500Medicaid
H51043Medicare UPIN