1336243971 NPI number — DR. LIDO L PETRUCCI DC

Table of content: DR. LIDO L PETRUCCI DC (NPI 1336243971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336243971 NPI number — DR. LIDO L PETRUCCI DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRUCCI
Provider First Name:
LIDO
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1336243971
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 S 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGRANGE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40031-1240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-222-0000
Provider Business Mailing Address Fax Number:
502-222-3488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 S 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40031-1240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-222-0000
Provider Business Practice Location Address Fax Number:
502-222-3488
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4315 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2438072000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 9943660003 . This is a "CIGNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 0974279 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000051634 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 350048657 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1140365 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 85036697 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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