Provider Demographics
NPI:1942396403
Name:PERUSICH, MICHAEL R (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:PERUSICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 THOMPSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2241
Mailing Address - Country:US
Mailing Address - Phone:660-829-2600
Mailing Address - Fax:660-829-2607
Practice Address - Street 1:910 THOMPSON BLVD
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301
Practice Address - Country:US
Practice Address - Phone:660-829-2600
Practice Address - Fax:660-829-2607
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999134950111N00000X
KS01-04637111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
N76A188Medicare ID - Type Unspecified
U77396Medicare UPIN