Healthcare Provider Details

I. General information

NPI: 1346657889
Provider Name (Legal Business Name): BRUNO ALDO PEROSSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

9400 ZANE AVE N
BROOKLYN PARK MN
55443-1814
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-4103
  • Fax:
Mailing address:
  • Phone: 763-762-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101270199
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101270199
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number31174
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: