Basic Information
| Provider Information | |||||||||
| NPI: | 1669995395 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PERLBERG | ||||||||
| FirstName: | LOREN | ||||||||
| MiddleName: | EVOLA | ||||||||
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| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 596 S GLENHURST DR | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480094404 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006536568 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2017 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 201701010929 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LG0600X | 4704289626 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.