Provider Demographics
NPI:1811073109
Name:PERRY, FREDERICK BRUCE (DO)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:BRUCE
Last Name:PERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORT BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61275-9307
Mailing Address - Country:US
Mailing Address - Phone:563-529-4411
Mailing Address - Fax:
Practice Address - Street 1:1012 S HIGH ST
Practice Address - Street 2:
Practice Address - City:PORT BYRON
Practice Address - State:IL
Practice Address - Zip Code:61275-9307
Practice Address - Country:US
Practice Address - Phone:563-529-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D46445Medicare UPIN