1396761276 NPI number — DR. ROBERT PERZACKI M.D.

Table of content: DR. ROBERT PERZACKI M.D. (NPI 1396761276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396761276 NPI number — DR. ROBERT PERZACKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERZACKI
Provider First Name:
ROBERT
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396761276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1820 APPLETON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENASHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54952-1110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-996-2200
Provider Business Mailing Address Fax Number:
920-996-2214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1820 APPLETON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENASHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54952-1110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-996-2200
Provider Business Practice Location Address Fax Number:
920-996-2214
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  47360 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 42925-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1043361 . This is a "P1" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 405L5PE . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1396761276 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 378616100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 48630 . This is a "HP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 104348 . This is a "UC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 15-55187 . This is a "UBH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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