MEDICARE: ROBERT K. PETRELLI, OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)	PA-OE004707L	PA
2	332BC3200X	Customized Equipment (DME)	NJ3013	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0097739000	OTHER	NJ	AMERIHEALTH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	455040	OTHER	NJ	AETNA

General Provider Information

NPI Number	:	1083896153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERT K. PETRELLI, OD

Provider Business Mailing Address
First Line	:	1400 NEW JERSEY AVE
Second Line	:
City	:	NORTH WILDWOOD
State	:	NJ
Zip	:	08260-2738
Country	:	US
Telephone Number	:	609-522-4199
Fax Number	:	609-522-3692

Provider Business Practice Location Address
First Line	:	1400 NEW JERSEY AVE
Second Line	:
City	:	NORTH WILDWOOD
State	:	NJ
Zip	:	08260-2738
Country	:	US
Telephone Number	:	609-522-4199
Fax Number	:	609-522-3692

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROBERT K PETRELLI SR.
Credential	:	D.O.
Telephone Number	:	609-522-4199

Provider Enumeration Date	:	11/30/2007
Last Update Date	:	12/04/2007

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