Provider Demographics
NPI:1538567177
Name:PETRILLI, MATTHEW ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:PETRILLI
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 1:504 WILBORN AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-3120
Mailing Address - Country:US
Mailing Address - Phone:434-517-3400
Mailing Address - Fax:
Practice Address - Street 1:504 WILBORN AVE FL 5
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-3120
Practice Address - Country:US
Practice Address - Phone:434-517-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-14
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-003012084P0800X
VA01012671152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC87-204216OtherPSYCHIATRY