1063628956 NPI number — DR. TAMY E PERNG D.O.

Table of content: DR. TAMY E PERNG D.O. (NPI 1063628956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063628956 NPI number — DR. TAMY E PERNG D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERNG
Provider First Name:
TAMY
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1063628956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 HOSPITAL DR
Provider Second Line Business Mailing Address:
STE 2000
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53098-3320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-660-7616
Provider Business Mailing Address Fax Number:
765-651-7313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 N WABASH
Provider Second Line Business Practice Location Address:
SUITE 370
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46952-2678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-660-7500
Provider Business Practice Location Address Fax Number:
765-662-4724
Provider Enumeration Date:
05/15/2007

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: 208600000X , with the licence number:  0102202410 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: DO2928 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 02004094A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1063628956 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000784523 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201115230 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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