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General NPI Number Information
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NPI Number | 1902800972
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Entity Type | Individual
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Provider Name | RICHARD PETRELLA SR. MD
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Gender | Male
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Dates
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Enumeration Date | 06/08/2005
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Last Update Date | 08/28/2023
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Provider Practice Location Address
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Address Line | 1497 FAIR RD STE 205
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City | STATESBORO
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State | GA
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Zip | 30458-0824
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Country | US
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Telephone | 912-259-9881
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Fax | 912-259-9883
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Provider Business Mailing Address
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Address Line | 1497 FAIR RD STE 205
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City | STATESBORO
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State | GA
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Zip | 30458-0824
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Country | US
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Telephone | 912-259-9881
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Fax | 912-259-9883
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0011X
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Taxonomy Name | Interventional Cardiology Physician
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License Number | MD031766-E
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207RI0011X
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Taxonomy Name | Interventional Cardiology Physician
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License Number | 94630
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License Number State | GA
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