MEDICARE: J.I. PERALES MDPA

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	207R00000X	Internal Medicine Physician	E3403	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00QB44	OTHER		BLUE CROSS

General Provider Information

NPI Number	:	1790711281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J.I. PERALES MDPA

Provider Business Mailing Address
First Line	:	PO BOX 3188
Second Line	:
City	:	BORGER
State	:	TX
Zip	:	79008-3188
Country	:	US
Telephone Number	:	806-273-7118
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 S MCGEE ST
Second Line	:
City	:	BORGER
State	:	TX
Zip	:	79007-4022
Country	:	US
Telephone Number	:	806-273-7118
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JESSE I PERALES
Credential	:	MD
Telephone Number	:	806-273-7118

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	09/26/2007

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