Provider Demographics
NPI:1114997830
Name:PETRILLA, DIANE L (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:PETRILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1225 E WEISGARBER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:2240 SUTHERLAND AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-2333
Practice Address - Country:US
Practice Address - Phone:865-909-0090
Practice Address - Fax:865-909-9883
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN017129207Q00000X
SC32266207Q00000X
NH15138207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3373633OtherMEDICARE GROUP ID
3020296Medicare ID - Type Unspecified
A98394Medicare UPIN