Provider Demographics
NPI:1144258260
Name:MCFILLIN PETRONGOLO, TERRI A (DO)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:A
Last Name:MCFILLIN PETRONGOLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 CHESTNUT STREET
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3237
Mailing Address - Country:US
Mailing Address - Phone:215-662-8777
Mailing Address - Fax:
Practice Address - Street 1:3819 CHESTNUT STREET
Practice Address - Street 2:SUITE 205
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3237
Practice Address - Country:US
Practice Address - Phone:215-662-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010339L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019243100002Medicaid
PA063681Medicare ID - Type Unspecified
PA0019243100002Medicaid