Provider Demographics
NPI:1689619835
Name:PETRELLA, ROBERT JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
Last Name:PETRELLA
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 1:103 SANBORN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-3834
Mailing Address - Country:US
Mailing Address - Phone:617-323-6676
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:FAULKNER HOSPITAL EMERGENCY DEPARTMENT
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75111207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3110613Medicaid
MAJ13837OtherBLUE SHIELD
MA075111OtherTUFTS
MAF61365Medicare UPIN
MA3110613Medicaid