Provider Demographics
NPI:1790775013
Name:PETICCA, BENJAMIN BERNARD (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BERNARD
Last Name:PETICCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:B BERNARD
Other - Middle Name:
Other - Last Name:PETICCA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2580 HAYMAKER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-3500
Mailing Address - Country:US
Mailing Address - Phone:412-856-7500
Mailing Address - Fax:412-856-6079
Practice Address - Street 1:2580 HAYMAKER RD STE 201
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-3500
Practice Address - Country:US
Practice Address - Phone:412-856-7500
Practice Address - Fax:412-856-6079
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025238E207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001022620Medicaid
412898Medicare PIN
PA001022620Medicaid
PA001022620003Medicaid
PA412898R7RMedicare PIN