Provider Demographics
NPI:1447303185
Name:PETRUSO, ROBERT WILLIAM (BA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:PETRUSO
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3334
Mailing Address - Country:US
Mailing Address - Phone:814-724-6211
Mailing Address - Fax:
Practice Address - Street 1:937 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3334
Practice Address - Country:US
Practice Address - Phone:814-724-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF02267237700000X, 156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01943398Medicaid
PAPE067038Medicare ID - Type Unspecified