Provider Demographics
NPI:1063628956
Name:PERNG, TAMY E (DO)
Entity Type:Individual
Prefix:DR
First Name:TAMY
Middle Name:E
Last Name:PERNG
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:123 HOSPITAL DR
Mailing Address - Street 2:STE 2000
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3320
Mailing Address - Country:US
Mailing Address - Phone:765-660-7616
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:330 N WABASH
Practice Address - Street 2:SUITE 370
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2678
Practice Address - Country:US
Practice Address - Phone:765-660-7500
Practice Address - Fax:765-662-4724
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2019-09-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0102202410208600000X
MEDO2928208600000X
IN02004094A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063628956Medicaid
IN000000784523OtherANTHEM
IN201115230Medicaid
IN201115230Medicaid