Provider Demographics
NPI:1578684189
Name:PERIUS, MARK ALLEN (RD, MSA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:PERIUS
Suffix:
Gender:M
Credentials:RD, MSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50201 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-4303
Mailing Address - Country:US
Mailing Address - Phone:248-790-7944
Mailing Address - Fax:
Practice Address - Street 1:50201 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-4303
Practice Address - Country:US
Practice Address - Phone:248-790-7944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Not Answered133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic