1750333084 NPI number — ROBERT WILLIAM PETRUSO II AUD

Table of content: (NPI 1356437420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750333084 NPI number — ROBERT WILLIAM PETRUSO II AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRUSO
Provider First Name:
ROBERT
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
AUD
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:
1750333084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14470 HARMONSBURG RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEADVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16335-8760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
937 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16335-3334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-724-6211
Provider Business Practice Location Address Fax Number:
814-337-0188
Provider Enumeration Date:
05/16/2006

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: 231H00000X , with the licence number:  AT005853 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 231H00000X , with the licence number: A01527 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X , with the licence number: 346 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 314148 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000375162 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0015214050001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 251916413 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 219759 . This is a "HIGHMARK BC/BS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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