Provider Demographics
NPI:1477502508
Name:PERUSSE, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PERUSSE
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 1:10401 SPOTSYLVANIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-8606
Mailing Address - Country:US
Mailing Address - Phone:540-361-1000
Mailing Address - Fax:540-361-7010
Practice Address - Street 1:1001 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4453
Practice Address - Country:US
Practice Address - Phone:540-361-1000
Practice Address - Fax:540-361-7010
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012324372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
54-1364028OtherTAX ID
54-0972713OtherTAX ID
300131652Medicare PIN
VA300002552Medicare PIN
54-0972713OtherTAX ID
300130259Medicare PIN
G42014Medicare UPIN
54-0972713OtherTAX ID