Provider Demographics
NPI:1922280403
Name:PERRY, THOMAS RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RUSSELL
Last Name:PERRY
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 1:2229 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-2116
Mailing Address - Country:US
Mailing Address - Phone:608-325-6664
Mailing Address - Fax:608-299-3745
Practice Address - Street 1:611 SHERMAN AVE E
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1960
Practice Address - Country:US
Practice Address - Phone:920-568-5334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI226192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31804600Medicaid
WI569574OtherDEAN HEALTH PLAN
WI31804600Medicaid
WI000114035Medicare PIN