Provider Demographics
NPI:1740239755
Name:PERILLO, MICHAEL J JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:PERILLO
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1637
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-1637
Mailing Address - Country:US
Mailing Address - Phone:803-407-5266
Mailing Address - Fax:803-407-1455
Practice Address - Street 1:21 STONEBRIAR RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-8531
Practice Address - Country:US
Practice Address - Phone:803-407-5266
Practice Address - Fax:803-407-1455
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC882367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0953Medicaid
SCAN0953Medicaid