Basic Information
| Provider Information | |||||||||
| NPI: | 1487636874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRACCA | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 IRONGATE CENTER | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128013471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187934409 | ||||||||
| FaxNumber: | 5187935886 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 IRONGATE CENTER | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128013471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187934409 | ||||||||
| FaxNumber: | 5187935886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2005 | ||||||||
| LastUpdateDate: | 02/13/2008 | ||||||||
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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 | 207Q00000X | 167575 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000401245001 | 01 | NY | BLUE SHIELD NENY | OTHER | CD1981 | 01 | NY | RAILROAD MEDICARE GROUP # | OTHER | 10470641 | 01 | NY | CAQH | OTHER | 5500215 | 01 | NY | AETNA | OTHER | 01346818 | 05 | NY | MEDICAID | 10002650 | 01 | NY | CDPHP | OTHER | 56K521 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | 000000056116 | 01 | NY | GHI-HMO | OTHER | 00020592301 | 01 | NY | UNIVERA | OTHER | 021200700350 | 01 | NY | FIDELIS | OTHER | 08219 | 01 | NY | MVP | OTHER |