=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982004883
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARKO PEROVIC M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2014
-----------------------------------------------------
Last Update Date | 04/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 E AJO WAY
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85713-6204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-874-2747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 N CAMPBELL AVE RM 6204A
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85724-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-626-3894
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084V0102X
-----------------------------------------------------
Taxonomy Name | Vascular Neurology Physician
-----------------------------------------------------
License Number | 57759
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------