Provider Demographics
NPI:1033144233
Name:PETRILLO, JOHN M (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:PETRILLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:624 MCCLELLAN STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1020
Mailing Address - Country:US
Mailing Address - Phone:518-382-2260
Mailing Address - Fax:518-347-5007
Practice Address - Street 1:624 MCCLELLAN STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1020
Practice Address - Country:US
Practice Address - Phone:518-382-2260
Practice Address - Fax:518-347-5007
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY070216000066OtherFIDELIS
NY200391OtherSENIOR WHOLE HEALTH
NY4148P1OtherEMPIRE BC
NY4149233OtherMVP
NY000412108002OtherBSNENY
NY111639OtherGHI HMO
NY7488829OtherAETNA
NY02770294Medicaid
NYCDPHPOther10112887
NYRB0763Medicare ID - Type UnspecifiedMEDICARE
NY4148P1OtherEMPIRE BC
NYRB8334Medicare PIN