1912976267 NPI number — DR. ROBERT CORTESE PETRUCELLI MD, PA

Table of content: MS. TERI LYNN JOHNSON (NPI 1558659094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912976267 NPI number — DR. ROBERT CORTESE PETRUCELLI MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRUCELLI
Provider First Name:
ROBERT
Provider Middle Name:
CORTESE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PA
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:
1912976267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 SUNSET STRIP
Provider Second Line Business Mailing Address:
STE 208
Provider Business Mailing Address City Name:
SUCCASUNNA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-252-0333
Provider Business Mailing Address Fax Number:
973-252-0220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 SUNSET STRIP
Provider Second Line Business Practice Location Address:
STE 208
Provider Business Practice Location Address City Name:
SUCCASUNNA
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-252-0333
Provider Business Practice Location Address Fax Number:
973-252-0220
Provider Enumeration Date:
03/17/2006

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: 174400000X , with the licence number:  25MA03332600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 25MA03332600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110942 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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