MEDICARE: DR. GABRIEL L PETRUCCELLI MD

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	207X00000X	Orthopaedic Surgery Physician	A117457	CA

General Provider Information

NPI Number	:	1255623690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GABRIEL L PETRUCCELLI MD

Provider Business Mailing Address
First Line	:	1400 FOREST GLEN ROAD
Second Line	:	SUITE 400
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-1482
Country	:	US
Telephone Number	:	301-589-3324
Fax Number	:	301-681-7575

Provider Business Practice Location Address
First Line	:	1400 FOREST GLEN ROAD
Second Line	:	SUITE 400
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-1482
Country	:	US
Telephone Number	:	301-589-3324
Fax Number	:	301-681-7575

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

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	10/12/2012

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