Provider Demographics
NPI:1750333084
Name:PETRUSO, ROBERT WILLIAM II (AUD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:PETRUSO
Suffix:II
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14470 HARMONSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-8760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:937 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3334
Practice Address - Country:US
Practice Address - Phone:814-724-6211
Practice Address - Fax:814-337-0188
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT005853231H00000X
OHA01527231H00000X
OK346231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA314148OtherUPMC
OH000000375162OtherANTHEM BC/BS
PA0015214050001Medicaid
OH251916413OtherUNITED HEALTHCARE
PA219759OtherHIGHMARK BC/BS
PA0015214050001Medicaid
OHPE4159071Medicare ID - Type UnspecifiedPROVIDER NUMBER