Provider Demographics
NPI:1518014331
Name:GHERAIBEH, PETRA (MD)
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:GHERAIBEH
Suffix:
Gender:F
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:PO BOX 100523
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-0523
Mailing Address - Country:US
Mailing Address - Phone:843-669-5162
Mailing Address - Fax:843-667-4573
Practice Address - Street 1:1001 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2848
Practice Address - Country:US
Practice Address - Phone:843-527-4447
Practice Address - Fax:843-527-6423
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL34052207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC340526Medicaid