Provider Demographics
NPI:1285605329
Name:PERZANOWSKI, PETER EUGENE (DC)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:EUGENE
Last Name:PERZANOWSKI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 206
Mailing Address - Street 2:300 HOWARD ST STE 2
Mailing Address - City:BRIDGEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43912
Mailing Address - Country:US
Mailing Address - Phone:740-633-3161
Mailing Address - Fax:740-633-3161
Practice Address - Street 1:300 HOWARD ST
Practice Address - Street 2:STE 2
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912
Practice Address - Country:US
Practice Address - Phone:740-633-3161
Practice Address - Fax:740-633-3161
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
0132022000OtherWV MEDICAID
OH0661172Medicaid
1287AOtherTHE HEALTH PLAN PROVIDER
OH34177511100OtherOHIO WORK COMP BWC
001716296OtherSERVICE ID #
1484138OtherHEATTHI RETIREAT FUNDS
001708126OtherPAY TO ID #
WV341775111OtherWV WORK COMP
1287OtherTHE HEALTH PLAN PROVIDER
4484446OtherAETNA
000000138352OtherANTHEM
1287AOtherTHE HEALTH PLAN PROVIDER
T48596Medicare UPIN