Provider Demographics
NPI:1205150091
Name:ROSELLE C. PETTORINO MD, PA
Entity type:Organization
Organization Name:ROSELLE C. PETTORINO MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ROSELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETTORINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:956-541-6311
Mailing Address - Street 1:864 CENTRAL BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-7539
Mailing Address - Country:US
Mailing Address - Phone:956-541-6311
Mailing Address - Fax:956-541-6387
Practice Address - Street 1:864 CENTRAL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-7539
Practice Address - Country:US
Practice Address - Phone:956-541-6311
Practice Address - Fax:956-541-6387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8420174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX212330901Medicaid
TX029740001Medicaid
TX029740001Medicaid