Provider Demographics
NPI:1801861331
Name:PETRICK, MARCIA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:LYNN
Last Name:PETRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-1726
Mailing Address - Country:US
Mailing Address - Phone:724-589-6200
Mailing Address - Fax:
Practice Address - Street 1:110 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-1726
Practice Address - Country:US
Practice Address - Phone:724-589-6200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD424461174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG60367Medicare UPIN
PA080171LRDMedicare ID - Type Unspecified