Provider Demographics
NPI:1528015559
Name:RUSSELL PERRY MD, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:RUSSELL PERRY MD, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:MYRON
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-261-7880
Mailing Address - Street 1:PO BOX 3222
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-0293
Mailing Address - Country:US
Mailing Address - Phone:707-261-7824
Mailing Address - Fax:707-256-3508
Practice Address - Street 1:700 RIVER DR
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5403
Practice Address - Country:US
Practice Address - Phone:707-961-4665
Practice Address - Fax:707-961-4780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G428120Medicaid
DA6000OtherRAILROAD MEDICARE PIN
CAZZZ27606ZMedicare ID - Type Unspecified
DA6000OtherRAILROAD MEDICARE PIN