1912177445 NPI number — HEATHER A PETROLLA

Table of content: (NPI 1912177445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912177445 NPI number — HEATHER A PETROLLA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEATHER A PETROLLA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912177445
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3507 CANFIELD RD
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
YOUNGSTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44511-2859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-793-0566
Provider Business Mailing Address Fax Number:
330-793-5767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 YOUNGSTOWN POLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STRUTHERS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44471-1305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-707-1360
Provider Business Practice Location Address Fax Number:
330-707-1359
Provider Enumeration Date:
03/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SCHULICK
Authorized Official First Name:
JOANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
330-793-0566

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  36.001865 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0409543 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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