Provider Demographics
NPI:1831164003
Name:PETRUCCI, DEAN
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:PETRUCCI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 BROOKSHIRE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-4513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 BROOKSHIRE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-4513
Practice Address - Country:US
Practice Address - Phone:724-346-3116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008666L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA729352PD7Medicare ID - Type Unspecified
PAG22734Medicare UPIN