Provider Demographics
NPI:1043280316
Name:SUBURBAN ORTHOPAEDICS PC
Entity Type:Organization
Organization Name:SUBURBAN ORTHOPAEDICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETOLILLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:215-750-6700
Mailing Address - Street 1:240 MIDDLETOWN BLVD
Mailing Address - Street 2:SUITE 101D
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-1832
Mailing Address - Country:US
Mailing Address - Phone:215-750-6700
Mailing Address - Fax:215-750-6706
Practice Address - Street 1:240 MIDDLETOWN BLVD
Practice Address - Street 2:SUITE 101D
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1832
Practice Address - Country:US
Practice Address - Phone:215-750-6700
Practice Address - Fax:215-750-6706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA200044351OtherTRAVELERS MEDICARE
989692OtherHIGHMARK BS
PA3938180001Medicare NSC
PA079586Medicare PIN