1033182662 NPI number — DR. WILLIAM R PETRICONE JR. MD

Table of content: DR. WILLIAM R PETRICONE JR. MD (NPI 1033182662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033182662 NPI number — DR. WILLIAM R PETRICONE JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRICONE
Provider First Name:
WILLIAM
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
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:
1033182662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 CHERRY ST
Provider Second Line Business Mailing Address:
SUITE 11511
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19102-1321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-255-7822
Provider Business Mailing Address Fax Number:
215-255-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1427 VINE ST
Provider Second Line Business Practice Location Address:
SIXTH FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19102-1031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-762-6565
Provider Business Practice Location Address Fax Number:
215-762-6997
Provider Enumeration Date:
02/13/2006

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: 207R00000X , with the licence number:  MD434949 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: MD434948 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 001367483 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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