MEDICARE: DR. JOSEPH C PETROCELLI 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	208600000X	Surgery Physician	20679	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2433736000	OTHER	KY	PASSPORT ADVANTAGE
2	611269278001	OTHER	KY	CHAMPUS
3	1054879	OTHER	KY	PASSPORT
4	000000050793	OTHER	KY	ANTHEM
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538162268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH C PETROCELLI MD

Provider Business Mailing Address
First Line	:	910 WALLACE AVE
Second Line	:
City	:	LEITCHFIELD
State	:	KY
Zip	:	42754-2414
Country	:	US
Telephone Number	:	270-259-3035
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 WALLACE AVE
Second Line	:
City	:	LEITCHFIELD
State	:	KY
Zip	:	42754-2414
Country	:	US
Telephone Number	:	270-259-3035
Fax Number	:

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	02/01/2012

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