Basic Information
Provider Information
NPI: 1033556998
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PERRINO
FirstName: ERICA
MiddleName: DAVIS
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 116 WEST BUCHANAN AVE.
Address2:  
City: CHARLESTON
State: IL
PostalCode: 61920
CountryCode: US
TelephoneNumber: 2173457700
FaxNumber: 2173457200
Practice Location
Address1: 116 WEST BUCHANAN AVE.
Address2:  
City: CHARLESTON
State: IL
PostalCode: 61920
CountryCode: US
TelephoneNumber: 2173457700
FaxNumber: 2173457200
Other Information
ProviderEnumerationDate: 05/31/2013
LastUpdateDate: 03/18/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X036138703ILY Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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