Provider Demographics
NPI:1457610156
Name:LOUIS J PETRACCA MD PA
Entity Type:Organization
Organization Name:LOUIS J PETRACCA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETRACCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-429-9225
Mailing Address - Street 1:332 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4806
Mailing Address - Country:US
Mailing Address - Phone:973-429-9225
Mailing Address - Fax:973-566-0973
Practice Address - Street 1:332 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-4806
Practice Address - Country:US
Practice Address - Phone:973-429-9225
Practice Address - Fax:973-566-0973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04021600207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP635038OtherOXFORD HEALTH PLANS
NJ2002507Medicaid
NJ525347Medicare PIN
NJP635038OtherOXFORD HEALTH PLANS