Provider Demographics
NPI:1972542603
Name:PETRALIA, PEGGY A (DO)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:A
Last Name:PETRALIA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:6420 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1811
Practice Address - Country:US
Practice Address - Phone:314-768-8000
Practice Address - Fax:314-768-8011
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100232207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1972542603Medicaid
MO1972542603Medicaid
MO150050017Medicare PIN