Provider Demographics
NPI:1154323004
Name:PETRILLI, EDMUND S (MD)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:S
Last Name:PETRILLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9304 FOREST POINT CIR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4700
Mailing Address - Country:US
Mailing Address - Phone:703-368-1969
Mailing Address - Fax:703-369-4164
Practice Address - Street 1:9304 FOREST POINT CIR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4700
Practice Address - Country:US
Practice Address - Phone:703-368-1969
Practice Address - Fax:703-369-4164
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101022700207VG0400X, 207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC35984Medicare UPIN
VA00V387E05Medicare PIN