1215918933 NPI number — DR. PASQUALE PETRERA M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215918933 NPI number — DR. PASQUALE PETRERA M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

PETRERA

Provider First Name:

PASQUALE

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

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:

1215918933

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/06/2008

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 2415

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SALISBURY

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21802-2415

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

410-749-4154

Provider Business Mailing Address Fax Number:

410-860-9583

Provider First Line Business Practice Location Address:

1675 WOODBROOKE DRIVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

SALISBURY

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

21804

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

410-749-4154

Provider Business Practice Location Address Fax Number:

410-860-9583

Provider Enumeration Date:

11/09/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207XS0114X , with the licence number:  D44707 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 3226879 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 588841700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 66G41 . This is a "EMPIRE BCBS" identifier . This identifiers is of the category "OTHER".
• Identifier: 006400248 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 217742 . This is a "MDIPA OPTIMUM CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 0000575601 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
• Identifier: 221921800 . This is a "US DEPARTMENT OF LABOR" identifier . This identifiers is of the category "OTHER".
• Identifier: 200022316 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 327279 . This is a "PRIME HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 52819001H524PE . This is a "BCBS TRAD PRODUCTS" identifier . This identifiers is of the category "OTHER".
• Identifier: 44707 . This is a "FREESTATE DELMARVA HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 0008W409 . This is a "BCBS PROD FEP BLUE CHOICE" identifier . This identifiers is of the category "OTHER".
• Identifier: 091051 . This is a "TRIGON BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".