1912062647 NPI number — PETRECCIA AND TROTTER MEDICAL CORPORATION

Table of content: (NPI 1912062647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912062647 NPI number — PETRECCIA AND TROTTER MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETRECCIA AND TROTTER MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INFECTIOUS DISEASE CONSULTANTS MED. OFFICE, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912062647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 N. ROSE DRIVE
Provider Second Line Business Mailing Address:
SUITE 134
Provider Business Mailing Address City Name:
PLACENTIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92870-3919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-996-6500
Provider Business Mailing Address Fax Number:
714-996-1722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 N. ROSE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 134
Provider Business Practice Location Address City Name:
PLACENTIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92870-3919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-996-6500
Provider Business Practice Location Address Fax Number:
714-996-1722
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TROTTER
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-996-6500

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  G65207 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: W15729 . This is a "PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0048130 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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