Healthcare Provider Details

I. General information

NPI: 1275668063
Provider Name (Legal Business Name): CITRUS ORTHOPAEDIC AND JOINT INSTITUTE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N AVALON WAY
LECANTO FL
34461-6004
US

IV. Provider business mailing address

PO BOX 1990
CRYSTAL RIVER FL
34423-1990
US

V. Phone/Fax

Practice location:
  • Phone: 352-746-2663
  • Fax: 352-746-6907
Mailing address:
  • Phone: 352-746-2663
  • Fax: 352-746-6907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME0074278
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberME0080012
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO0002716
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT20489
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT8397
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT3425
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108675
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA3291
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9101478
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA3291
License Number StateFL
# 11
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9101478
License Number StateFL

VIII. Authorized Official

Name: DR. ANDREW J PETRELLA
Title or Position: OWNER
Credential: MD
Phone: 352-746-2663