Provider Demographics
NPI:1881889491
Name:PERRY E ZACK DO
Entity type:Organization
Organization Name:PERRY E ZACK DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:ZACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-945-0090
Mailing Address - Street 1:1400 S LAKE PARK AVE
Mailing Address - Street 2:SUIT 405
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6636
Mailing Address - Country:US
Mailing Address - Phone:219-945-0090
Mailing Address - Fax:219-945-1118
Practice Address - Street 1:1400 S LAKE PARK AVE
Practice Address - Street 2:SUIT 405
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6636
Practice Address - Country:US
Practice Address - Phone:219-945-0090
Practice Address - Fax:219-945-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN148290Medicare PIN
INF33870Medicare UPIN