Provider Demographics
NPI:1477641413
Name:PETRALLO, SCOTT W (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:W
Last Name:PETRALLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 KIRK RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-1839
Mailing Address - Country:US
Mailing Address - Phone:330-793-0711
Mailing Address - Fax:330-793-9419
Practice Address - Street 1:4241 KIRK RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-1839
Practice Address - Country:US
Practice Address - Phone:330-793-0711
Practice Address - Fax:330-793-9419
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1547116OtherGATEWAY (MEDICAID
OH2305697Medicaid
OH4070841Medicare ID - Type Unspecified
OH2305697Medicaid