Basic Information
| Provider Information | |||||||||
| NPI: | 1851321442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17541 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841170541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012321633 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 W 5TH AVE STE 900 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098382531 | ||||||||
| FaxNumber: | 5097556580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 10502 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 10502 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 10502 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | MD60421229 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | MD60421229 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207R00000X | MD60421229 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000098585 | 01 | MT | BLUE CROSS BLUE SHIELD MT | OTHER | 1851321442 | 05 | MT | MEDICAID |