Provider Demographics
NPI:1306835004
Name:SEVERANCE, PERRY J (MD)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:J
Last Name:SEVERANCE
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 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-262-5131
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25579207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1000006OtherPREFERRED ONE
108496OtherU-CARE
600819OtherARAZ GRP/AMERICA'S PPO
045098700OtherMEDICAL ASSISTANCE
6D089SEOtherBLUE CROSS BLUE SHIELD
449000005OtherMEDICARE
HP22744OtherHEALTH PARTNERS
9227216OtherMEDICA HEALTH PLANS
2114131OtherFIRST HEALTH PLAN
D75711Medicare UPIN