MEDICARE: LOUIS DANIEL PETRELLIS DO

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	207Q00000X	Family Medicine Physician	0S006198L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235161662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOUIS DANIEL PETRELLIS DO

Provider Business Mailing Address
First Line	:	1718 WELSH RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-4241
Country	:	US
Telephone Number	:	215-673-1444
Fax Number	:	215-673-1704

Provider Business Practice Location Address
First Line	:	1718 WELSH RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-4241
Country	:	US
Telephone Number	:	215-673-1700
Fax Number	:	215-673-1704

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	12/30/2019

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