Basic Information
| Provider Information | |||||||||
| NPI: | 1033182662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRICONE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 11511 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1427 VINE ST | ||||||||
| Address2: | SIXTH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157626565 | ||||||||
| FaxNumber: | 2157626997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD434949 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD434948 | PA | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 001367483 | 05 | CT | MEDICAID |