Basic Information
| Provider Information | |||||||||
| NPI: | 1144336470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRAIUOLO | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 714328 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432714328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003541985 | ||||||||
| FaxNumber: | 4403504938 | ||||||||
| Practice Location | |||||||||
| Address1: | 36060 EUCLID AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406026553 | ||||||||
| FaxNumber: | 4406026566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 09/06/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35061722 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0836975 | 05 | OH | MEDICAID |