Healthcare Provider Details

I. General information

NPI: 1205823200
Provider Name (Legal Business Name): MICHAEL LEE PERGAMENT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SHERMAN ST SUITE 400
SAINT PAUL MN
55102-2564
US

IV. Provider business mailing address

2550 UNIVERSITY AVE W SUITE 240N
SAINT PAUL MN
55114-1052
US

V. Phone/Fax

Practice location:
  • Phone: 651-999-6800
  • Fax: 651-999-6910
Mailing address:
  • Phone: 651-999-6909
  • Fax: 651-297-6115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number20526
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: