Provider Demographics
NPI:1245787530
Name:ERIC E. PETTERSON P.C.
Entity Type:Organization
Organization Name:ERIC E. PETTERSON P.C.
Other - Org Name:BREAKTHROUGHHEALTHPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:PETTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-462-1040
Mailing Address - Street 1:411 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:MAHANOY CITY
Mailing Address - State:PA
Mailing Address - Zip Code:17948-2515
Mailing Address - Country:US
Mailing Address - Phone:570-861-0802
Mailing Address - Fax:570-462-1040
Practice Address - Street 1:1 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:PA
Practice Address - Zip Code:17976-2332
Practice Address - Country:US
Practice Address - Phone:570-462-1040
Practice Address - Fax:570-462-1042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-05
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039636L207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010036980010Medicaid
PA0010036980006Medicaid