Healthcare Provider Details

I. General information

NPI: 1023004223
Provider Name (Legal Business Name): REBECCA D PERRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W GLEN ST
CRANDON WI
54520-1355
US

IV. Provider business mailing address

400 W GLEN ST
CRANDON WI
54520-1355
US

V. Phone/Fax

Practice location:
  • Phone: 715-478-3318
  • Fax: 715-478-3255
Mailing address:
  • Phone: 715-478-3318
  • Fax: 715-478-3255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22328
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: