Provider Demographics
NPI:1700872884
Name:PERRY, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:PERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6503 E BROAD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1692
Mailing Address - Country:US
Mailing Address - Phone:614-434-5437
Mailing Address - Fax:614-434-5438
Practice Address - Street 1:6503 E BROAD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1692
Practice Address - Country:US
Practice Address - Phone:614-434-5437
Practice Address - Fax:614-434-5438
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-061867208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0886626Medicaid
OHE96524Medicare UPIN
OH0886626Medicaid