Provider Demographics
NPI:1942266788
Name:PETRUSICK, THOMAS WILLIAM (MD)
Entity Type:Individual
Prefix:MS
First Name:THOMAS
Middle Name:WILLIAM
Last Name:PETRUSICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8120 ROURK ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4127
Mailing Address - Country:US
Mailing Address - Phone:843-449-1438
Mailing Address - Fax:843-286-1349
Practice Address - Street 1:8120 ROURK ST
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4127
Practice Address - Country:US
Practice Address - Phone:843-449-1438
Practice Address - Fax:843-286-1349
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7085208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570783896OtherFED TAX ID