Basic Information
| Provider Information | |||||||||
| NPI: | 1134237506 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERRIZO | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012613737 | ||||||||
| FaxNumber: | 6012613899 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 THORNHILL DR | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012613737 | ||||||||
| FaxNumber: | 6012613899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2006 | ||||||||
| LastUpdateDate: | 03/27/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 14998 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00117260 | 05 | MS | MEDICAID | 640507572AO | 01 | MS | AMERICAN ADMIN GROUP | OTHER |