MEDICARE: DR. JOHN THOMAS PERICLES D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MB58296	NJ

General Provider Information

NPI Number	:	1144363250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN THOMAS PERICLES D.O.

Provider Business Mailing Address
First Line	:	112 MORRIS AVE
Second Line	:
City	:	EGG HARBOR TWP
State	:	NJ
Zip	:	08234-8521
Country	:	US
Telephone Number	:	609-927-0554
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 BOARDWALK
Second Line	:	WHOLE HEALTH WELLNESS CENTER
City	:	ATLANTIC CITY
State	:	NJ
Zip	:	08401-7509
Country	:	US
Telephone Number	:	609-343-4003
Fax Number	:	609-343-4006

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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