Basic Information
| Provider Information | |||||||||
| NPI: | 1063684215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETILLO | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1330 BOILING SPRINGS RD | ||||||||
| Address2: | STE 1400 | ||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293034205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642781273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953300 | ||||||||
| FaxNumber: | 7042953468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 7312 | NC | Y | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 3886 | SC | N | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1618R | 01 | NC | BCBSNC | OTHER | 5939044 | 01 | NC | CIGNA | OTHER | 7413356 | 05 | NC | MEDICAID | 770333 | 01 | WELLCARE | OTHER | P01044436 | 01 | SC | RAILROAD MEDICARE | OTHER | 9873230 | 01 | NC | AETNA | OTHER | P01450607 | 01 | NC | RAILROAD MEDICARE | OTHER | 30111366 | 01 | SC | SELECT HEALTH OF SOUTH CAROLINA | OTHER | SA1085 | 05 | SC | MEDICAID |