Provider Demographics
NPI:1699762963
Name:DR. M. PELOSI, MD PA
Entity type:Organization
Organization Name:DR. M. PELOSI, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:PELOSI
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:201-858-1800
Mailing Address - Street 1:350 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-1313
Mailing Address - Country:US
Mailing Address - Phone:201-858-1800
Mailing Address - Fax:201-858-1002
Practice Address - Street 1:350 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-1313
Practice Address - Country:US
Practice Address - Phone:201-858-1800
Practice Address - Fax:201-858-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA27105207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ057510Medicare PIN