Provider Demographics
NPI:1437518479
Name:PERRY, STEWARD ANTONIO
Entity Type:Individual
Prefix:
First Name:STEWARD
Middle Name:ANTONIO
Last Name:PERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S WALNUT BEND RD
Mailing Address - Street 2:10
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7283
Mailing Address - Country:US
Mailing Address - Phone:901-842-1770
Mailing Address - Fax:
Practice Address - Street 1:320 S WALNUT BEND RD
Practice Address - Street 2:10
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7283
Practice Address - Country:US
Practice Address - Phone:901-842-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ017979Medicaid