Provider Demographics
NPI:1083673024
Name:PERRIN, EDWARD J (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:PERRIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20940 N TATUM BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7273
Mailing Address - Country:US
Mailing Address - Phone:480-607-0060
Mailing Address - Fax:480-607-5809
Practice Address - Street 1:20940 N TATUM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7273
Practice Address - Country:US
Practice Address - Phone:480-607-0060
Practice Address - Fax:480-607-5809
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ789828Medicaid
Z74766Medicare PIN
AZ789828Medicaid