Healthcare Provider Details

I. General information

NPI: 1902800972
Provider Name (Legal Business Name): RICHARD PETRELLA SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 FAIR RD STE 205
STATESBORO GA
30458-0824
US

IV. Provider business mailing address

1497 FAIR RD STE 205
STATESBORO GA
30458-0824
US

V. Phone/Fax

Practice location:
  • Phone: 912-259-9881
  • Fax: 912-259-9883
Mailing address:
  • Phone: 912-259-9881
  • Fax: 912-259-9883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD031766-E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number94630
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: