Basic Information
Provider Information | |||||||||
NPI: | 1063406700 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PERRY | ||||||||
FirstName: | MARIA | ||||||||
MiddleName: | B. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 36123 SCHOOLCRAFT RD | ||||||||
Address2: |   | ||||||||
City: | LIVONIA | ||||||||
State: | MI | ||||||||
PostalCode: | 481501216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7344640887 | ||||||||
FaxNumber: | 7344020254 | ||||||||
Practice Location | |||||||||
Address1: | 36123 SCHOOLCRAFT RD | ||||||||
Address2: |   | ||||||||
City: | LIVONIA | ||||||||
State: | MI | ||||||||
PostalCode: | 481501216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7344640887 | ||||||||
FaxNumber: | 7344020254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2005 | ||||||||
LastUpdateDate: | 09/09/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301065852 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 4301065852 | MI | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 1063406700 | 01 | MI | NPI # | OTHER | 4846600 | 05 | MI |   | MEDICAID | MS065852 | 01 | MI | BCBSM | OTHER | 70-0-F32947-0 | 01 | FM | BCBS CPIN # | OTHER |