Provider Demographics
NPI:1770582033
Name:PETRELLA, EDWARD J (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
Last Name:PETRELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:SOUTH JERSEY RADIOLOGY ASSOCIATES, PA
Mailing Address - Street 2:PO BOX 23355
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07189-0001
Mailing Address - Country:US
Mailing Address - Phone:856-770-0300
Mailing Address - Fax:856-770-0395
Practice Address - Street 1:100 CARNIE BLVD
Practice Address - Street 2:SUITE B-5
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4512
Practice Address - Country:US
Practice Address - Phone:856-751-0123
Practice Address - Fax:856-751-0535
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA023352002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1089884OtherHORIZON NJ HEALTH
300047117OtherRAILROAD MEDICARE
1243590OtherUNITED HEALTHCARE
PE000869OtherPREMIER BLUE
0069675000OtherAMERIHEALTH
A3738029OtherOXFORD HEALTH
PE000869OtherHIGHMARK PA BLUE SHIELD
0804225OtherAETNA
NJ1161407Medicaid
0804225OtherAETNA
A3738029OtherOXFORD HEALTH