Provider Demographics
NPI:1285770214
Name:PELLICORO, JILL A (MD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:A
Last Name:PELLICORO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9692 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3670
Mailing Address - Country:US
Mailing Address - Phone:301-599-7300
Mailing Address - Fax:301-599-0476
Practice Address - Street 1:9692 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3670
Practice Address - Country:US
Practice Address - Phone:301-599-7300
Practice Address - Fax:301-599-0476
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0055269208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407983300Medicaid