1063413706 NPI number — DR. GHISLAIN RICHARD PERRON MD

Table of content: DR. GHISLAIN RICHARD PERRON MD (NPI 1063413706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063413706 NPI number — DR. GHISLAIN RICHARD PERRON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERRON
Provider First Name:
GHISLAIN
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1063413706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 YELLOW BLUFF TRCE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT MARYS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31558-4395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-882-1298
Provider Business Mailing Address Fax Number:
912-882-1295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 N 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLKSTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31537-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-496-2697
Provider Business Practice Location Address Fax Number:
912-496-1139
Provider Enumeration Date:
08/03/2005

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: 207Q00000X , with the licence number:  043741 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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