Provider Demographics
NPI:1760508584
Name:ROBERT C.PETRUCELLI, M.D., P.A.
Entity Type:Organization
Organization Name:ROBERT C.PETRUCELLI, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CORTESE
Authorized Official - Last Name:PETRUCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-252-0333
Mailing Address - Street 1:66 SUNSET STRIP
Mailing Address - Street 2:STE 208
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876
Mailing Address - Country:US
Mailing Address - Phone:973-252-0333
Mailing Address - Fax:973-252-0220
Practice Address - Street 1:66 SUNSET STRIP
Practice Address - Street 2:STE 208
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876
Practice Address - Country:US
Practice Address - Phone:973-252-0333
Practice Address - Fax:973-252-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA33326174400000X
NJ207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC54996Medicare UPIN
NJ1239830001Medicare NSC
NJ449916Medicare ID - Type Unspecified