Provider Demographics
NPI:1740289933
Name:PERISH, CRESSA K (MD)
Entity type:Individual
Prefix:
First Name:CRESSA
Middle Name:K
Last Name:PERISH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRESSA
Other - Middle Name:K
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1269
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4269
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:19550 GOVERNORS HWY
Practice Address - Street 2:SUITE 2650
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2125
Practice Address - Country:US
Practice Address - Phone:708-481-8600
Practice Address - Fax:708-915-7238
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068636Medicaid
IL036068636Medicaid
ILK29979Medicare PIN
IL214007Medicare PIN
ILDF4402Medicare PIN
ILP00365777Medicare PIN
IL214007Medicare PIN
ILK29979Medicare PIN