Provider Demographics
NPI:1538162268
Name:PETROCELLI, JOSEPH C (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:C
Last Name:PETROCELLI
Suffix:
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 1:910 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-2414
Mailing Address - Country:US
Mailing Address - Phone:270-259-3035
Mailing Address - Fax:
Practice Address - Street 1:910 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-2414
Practice Address - Country:US
Practice Address - Phone:270-259-3035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20679208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2433736000OtherPASSPORT ADVANTAGE
KY611269278001OtherCHAMPUS
KY1054879OtherPASSPORT
KY000000050793OtherANTHEM
KY64206790Medicaid
KY000000050793OtherANTHEM
KY611269278001OtherCHAMPUS