MEDICARE: DR. MICHAEL JOHN PETROCELLI D.P.M.

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	213ES0103X	Foot & Ankle Surgery Podiatrist	PO-2399	FL

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
2	4544600001	OTHER	FL	DMERC #
3	4574474	OTHER	FL	AETNA #
4	65356	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1811988165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL JOHN PETROCELLI D.P.M.

Provider Business Mailing Address
First Line	:	1715 HERITAGE TRL
Second Line	:	SUITE 204
City	:	NAPLES
State	:	FL
Zip	:	34112-8715
Country	:	US
Telephone Number	:	239-775-0019
Fax Number	:	239-775-0219

Provider Business Practice Location Address
First Line	:	1715 HERITAGE TRL
Second Line	:	SUITE 204
City	:	NAPLES
State	:	FL
Zip	:	34112-8715
Country	:	US
Telephone Number	:	239-775-0019
Fax Number	:	239-775-0219

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

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	08/25/2009

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