Healthcare Provider Details

I. General information

NPI: 1841320561
Provider Name (Legal Business Name): PETER MICHAEL PETRILLO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD 5.504 JENNIE SEALY HOSPITAL
GALVESTON TX
77555-0877
US

IV. Provider business mailing address

PO BOX 650859 DEPARTMENT 710
DALLAS TX
75265-0859
US

V. Phone/Fax

Practice location:
  • Phone: 409-266-7856
  • Fax: 602-938-4401
Mailing address:
  • Phone: 409-772-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22937
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7881
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number001288
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA22937
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: