Provider Demographics
NPI:1407037500
Name:EDMUND STEPHEN PETRILLI, M.D., P.C.
Entity Type:Organization
Organization Name:EDMUND STEPHEN PETRILLI, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:PETRILLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-830-8403
Mailing Address - Street 1:8650 SUDLEY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4419
Mailing Address - Country:US
Mailing Address - Phone:703-392-5157
Mailing Address - Fax:703-392-1347
Practice Address - Street 1:8650 SUDLEY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4419
Practice Address - Country:US
Practice Address - Phone:703-392-5157
Practice Address - Fax:703-392-1347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101022700207VG0400X, 207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty