Healthcare Provider Details

I. General information

NPI: 1710418629
Provider Name (Legal Business Name): MICHAEL PERISA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13241 RAVENNA RD
CHARDON OH
44024-9012
US

IV. Provider business mailing address

3262 YOUNGSTOWN KINGSVILLE RD
CORTLAND OH
44410-9487
US

V. Phone/Fax

Practice location:
  • Phone: 440-285-9166
  • Fax:
Mailing address:
  • Phone: 330-719-2105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.140689
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: