Basic Information
Provider Information | |||||||||
NPI: | 1164704169 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PERLMAN | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | MATTHEA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5579 VALENCIA PARK BLVD | ||||||||
Address2: |   | ||||||||
City: | HILLIARD | ||||||||
State: | OH | ||||||||
PostalCode: | 430268794 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6147693342 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 798 N COURT ST | ||||||||
Address2: |   | ||||||||
City: | CIRCLEVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 431131262 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7404203000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2011 | ||||||||
LastUpdateDate: | 04/19/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.12563-NP | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | RX.12563-EX1 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 0054620 | 05 | OH |   | MEDICAID |