Provider Demographics
NPI:1245269547
Name:PETTERSON, ERIC EVAN (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:EVAN
Last Name:PETTERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 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:570-462-1040
Mailing Address - Fax:570-462-1042
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039636L207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010036980010Medicaid
PA0010036980006Medicaid
PAB36426Medicare UPIN
PA0010036980002Medicaid