Basic Information
Provider Information | |||||||||
NPI: | 1194712158 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEREZ | ||||||||
FirstName: | MICHELE | ||||||||
MiddleName: | T. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 270 CHASTAIN RD NW | ||||||||
Address2: |   | ||||||||
City: | KENNESAW | ||||||||
State: | GA | ||||||||
PostalCode: | 301443012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704218005 | ||||||||
FaxNumber: | 7704245662 | ||||||||
Practice Location | |||||||||
Address1: | 270 CHASTAIN RD NW | ||||||||
Address2: |   | ||||||||
City: | KENNESAW | ||||||||
State: | GA | ||||||||
PostalCode: | 301443012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704218005 | ||||||||
FaxNumber: | 7704245662 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2005 | ||||||||
LastUpdateDate: | 06/29/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 048326 | GA | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 000955655A | 05 | GA |   | MEDICAID | 000955655F | 05 | GA |   | MEDICAID | 000955655G | 05 | GA |   | MEDICAID | 000955655E | 05 | GA |   | MEDICAID |