Provider Demographics
NPI:1578083614
Name:PETRULIS, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:PETRULIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:PETRULIS
Other - Last Name:WREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-4969
Mailing Address - Fax:614-293-6111
Practice Address - Street 1:2050 KENNY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3502
Practice Address - Country:US
Practice Address - Phone:614-293-4969
Practice Address - Fax:614-293-6111
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH351456252084N0400X
OH35.1456252084N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0498327Medicaid