Provider Demographics
NPI:1902800972
Name:PETRELLA, RICHARD SR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PETRELLA
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1497 FAIR RD STE 205
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0824
Mailing Address - Country:US
Mailing Address - Phone:912-259-9881
Mailing Address - Fax:912-259-9883
Practice Address - Street 1:1497 FAIR RD STE 205
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0824
Practice Address - Country:US
Practice Address - Phone:912-259-9881
Practice Address - Fax:912-259-9883
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031766-E207RI0011X
GA94630207RI0011X
NY195157-1207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001192307Medicaid
E36349Medicare UPIN