Provider Demographics
NPI:1033182662
Name:PETRICONE, WILLIAM R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:PETRICONE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1601 CHERRY ST
Mailing Address - Street 2:SUITE 11511
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1321
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:215-255-7825
Practice Address - Street 1:1427 VINE ST
Practice Address - Street 2:SIXTH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1031
Practice Address - Country:US
Practice Address - Phone:215-762-6565
Practice Address - Fax:215-762-6997
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-10-29
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Provider Licenses
StateLicense IDTaxonomies
PAMD434949207R00000X
PAMD434948208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001367483Medicaid
CT110008911Medicare ID - Type Unspecified
H18940Medicare UPIN