Provider Demographics
NPI:1104865690
Name:PERENCEVICH, ELI N (MD)
Entity Type:Individual
Prefix:DR
First Name:ELI
Middle Name:N
Last Name:PERENCEVICH
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:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-5793
Mailing Address - Fax:410-328-0248
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-5793
Practice Address - Fax:410-328-0248
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD57430207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1104865690Medicaid
MD611598-01OtherBLUE CROSS/BLUE SHIELD
MD611598-01OtherBLUE CROSS/BLUE SHIELD
DE1104865690Medicaid