Provider Demographics
NPI:1124299466
Name:HEATHER A. PETROLLA
Entity type:Organization
Organization Name:HEATHER A. PETROLLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-793-0566
Mailing Address - Street 1:3507 CANFIELD RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-2859
Mailing Address - Country:US
Mailing Address - Phone:330-793-0566
Mailing Address - Fax:330-793-5767
Practice Address - Street 1:3507 CANFIELD RD
Practice Address - Street 2:SUITE 7
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-2859
Practice Address - Country:US
Practice Address - Phone:330-793-0566
Practice Address - Fax:330-793-5767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.001865213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0500720003Medicare NSC