1912984170 NPI number — DR. VINCENT F PETRAGLIA D.O.

Table of content: ALI ALTAK (NPI 1477109486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912984170 NPI number — DR. VINCENT F PETRAGLIA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRAGLIA
Provider First Name:
VINCENT
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1912984170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 VALLEYBROOK RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
MC MURRAY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15317-3367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-941-5588
Provider Business Mailing Address Fax Number:
724-941-1458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 VALLEYBROOK RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
MC MURRAY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15317-3367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-941-5588
Provider Business Practice Location Address Fax Number:
724-941-1458
Provider Enumeration Date:
12/29/2005

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: 207Q00000X , with the licence number:  OS003395L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 080190708 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0006076950006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 156479 . This is a "PA-HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3017472 . This is a "AETNA-MCMURRAY OFFICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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