Provider Demographics
NPI:1366785479
Name:RICHARD M. PETRONELLA, MD.
Entity type:Organization
Organization Name:RICHARD M. PETRONELLA, MD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETRONELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-307-5479
Mailing Address - Street 1:PO BOX 16593
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85732-6593
Mailing Address - Country:US
Mailing Address - Phone:520-298-3800
Mailing Address - Fax:520-296-0979
Practice Address - Street 1:3705 N SWAN RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6939
Practice Address - Country:US
Practice Address - Phone:520-298-3800
Practice Address - Fax:520-296-0979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20559208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ES9766Medicare UPIN