=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356317861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL PEROUANSKY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2006
-----------------------------------------------------
Last Update Date | 12/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5832 WOODS EDGE RD
-----------------------------------------------------
City | FITCHBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53711-5144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-263-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5832 WOODS EDGE RD
-----------------------------------------------------
City | FITCHBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53711-5144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 44883
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------