Provider Demographics
NPI:1104913433
Name:BRUCE E PERRY MD
Entity type:Organization
Organization Name:BRUCE E PERRY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-471-6033
Mailing Address - Street 1:1619 NW HAWTHORNE AVE
Mailing Address - Street 2:#102
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-6008
Mailing Address - Country:US
Mailing Address - Phone:541-471-6033
Mailing Address - Fax:541-474-6874
Practice Address - Street 1:1619 NW HAWTHORNE AVE STE 102
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-6008
Practice Address - Country:US
Practice Address - Phone:541-471-6033
Practice Address - Fax:541-474-6874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16305207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096396Medicaid
F02225Medicare UPIN
OR096396Medicaid