Healthcare Provider Details

I. General information

NPI: 1740436195
Provider Name (Legal Business Name): SARA PINGUL PETRILLO II MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY STREET
PROVIDENCE RI
02903-5374
US

IV. Provider business mailing address

125 METRO CENTER BLVD SUITE 2000
WARWICK RI
02886
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5174
  • Fax: 401-889-3619
Mailing address:
  • Phone: 401-432-2500
  • Fax: 401-889-3619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1016593
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0068574
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101245056
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD037149
License Number StateDC
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD19288
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: