Provider Demographics
NPI:1144417387
Name:RUSSELL E. PERRY, M.D., P.A.
Entity Type:Organization
Organization Name:RUSSELL E. PERRY, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-423-1212
Mailing Address - Street 1:406 PALMETTO ST STE A
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7323
Mailing Address - Country:US
Mailing Address - Phone:386-423-1212
Mailing Address - Fax:386-423-5730
Practice Address - Street 1:406 PALMETTO ST STE A
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7323
Practice Address - Country:US
Practice Address - Phone:386-423-1212
Practice Address - Fax:386-423-5730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL64384OtherBCBS
FLK1305Medicare PIN
FLD57658Medicare UPIN