1174591275 NPI number — JEROME J PERRA MD

Table of content: JEROME J PERRA MD (NPI 1174591275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174591275 NPI number — JEROME J PERRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERRA
Provider First Name:
JEROME
Provider Middle Name:
J
Provider Name Prefix Text:
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:
1174591275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 COMMERCE DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-4925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-968-5042
Provider Business Mailing Address Fax Number:
651-968-5904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1285 NININGER RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55033-1086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-842-5412
Provider Business Practice Location Address Fax Number:
651-437-2988
Provider Enumeration Date:
03/14/2006

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: 207X00000X , with the licence number:  38049 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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