Provider Demographics
NPI:1639144165
Name:PERROTTA, CHARLES JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:PERROTTA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PRESQUE ISLE MIND-BODY WELLNESS CENTER
Mailing Address - Street 2:2500 PALERMO DR. SUITE 2
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506
Mailing Address - Country:US
Mailing Address - Phone:814-860-3179
Mailing Address - Fax:814-615-7400
Practice Address - Street 1:PRESQUE ISLE MIND-BODY WELLNESS CENTER
Practice Address - Street 2:2500 PALERMO DR. SUITE 2
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506
Practice Address - Country:US
Practice Address - Phone:814-860-3179
Practice Address - Fax:814-615-7400
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042761L174400000X
PAMD-042761-L2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No174400000XOther Service ProvidersSpecialist
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001937185Medicaid
PAH52303Medicare UPIN