Healthcare Provider Details

I. General information

NPI: 1811073109
Provider Name (Legal Business Name): FREDERICK BRUCE PERRY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 S HIGH ST
PORT BYRON IL
61275-9307
US

IV. Provider business mailing address

1012 S HIGH ST
PORT BYRON IL
61275-9307
US

V. Phone/Fax

Practice location:
  • Phone: 563-529-4411
  • Fax:
Mailing address:
  • Phone: 563-529-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: