Provider Demographics
NPI:1083822290
Name:ALBERT T PETROSINO MD & MEHRZAD GHAFGHAICHI MD PTR
Entity Type:Organization
Organization Name:ALBERT T PETROSINO MD & MEHRZAD GHAFGHAICHI MD PTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:PETROSINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-794-5732
Mailing Address - Street 1:2902 59TH ST W STE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7021
Mailing Address - Country:US
Mailing Address - Phone:941-794-5732
Mailing Address - Fax:941-795-5517
Practice Address - Street 1:2902 59TH ST W STE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7021
Practice Address - Country:US
Practice Address - Phone:941-794-5732
Practice Address - Fax:941-795-5517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-19
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67012207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF90030Medicare UPIN
FLF90032Medicare UPIN
FL26108ZMedicare ID - Type UnspecifiedMEHRZAD GHAFGHAICHI, M.D.
FL33255Medicare PIN
FL26113ZMedicare ID - Type UnspecifiedALBERT PETROSINO, M.D.