Provider Demographics
NPI:1467553743
Name:CRESSA PERISH MD SC
Entity Type:Organization
Organization Name:CRESSA PERISH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:CRESSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:PERISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-481-8600
Mailing Address - Street 1:PO BOX 1269
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4269
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:19550 GOVERNORS HWY
Practice Address - Street 2:SUITE 2650
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2125
Practice Address - Country:US
Practice Address - Phone:708-481-8600
Practice Address - Fax:708-915-7238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-068636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31601549OtherBCBSIL GROUP #
IL214007Medicare PIN
IL=========OtherTAX IDENTIFIDATION NUMBER
IL214007Medicare PIN