MEDICARE: RICHARD PETRELLA SR. 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	207RI0011X	Interventional Cardiology Physician	MD031766-E	PA
2	207RI0011X	Interventional Cardiology Physician	94630	GA

General Provider Information

NPI Number	:	1902800972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD PETRELLA SR. MD

Provider Business Mailing Address
First Line	:	1497 FAIR RD STE 205
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-0824
Country	:	US
Telephone Number	:	912-259-9881
Fax Number	:	912-259-9883

Provider Business Practice Location Address
First Line	:	1497 FAIR RD STE 205
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-0824
Country	:	US
Telephone Number	:	912-259-9881
Fax Number	:	912-259-9883

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

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	08/28/2023

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