=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992003792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANITA PETRUZZELLI MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2011
-----------------------------------------------------
Last Update Date | 03/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 HEBRON AVE
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-2489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-959-2758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 HEBRON AVE
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-2489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-959-2758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANITA PETRUZZELLI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 800-959-2758
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 034143
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------