Provider Demographics
NPI:1730174038
Name:PERRY, PHIL C (MD)
Entity type:Individual
Prefix:
First Name:PHIL
Middle Name:C
Last Name:PERRY
Suffix:
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 1:5102 YACHT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-8324
Mailing Address - Country:US
Mailing Address - Phone:904-387-5163
Mailing Address - Fax:904-387-5651
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:SUITE 1302
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-7420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46225207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00427215AMedicaid
FL041595200Medicaid
FL15980OtherBLUE CROSS BLUE SHIELD
FL041595200Medicaid
GA00427215AMedicaid