Basic Information
Provider Information | |||||||||
NPI: | 1205817236 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PERCHALSKI | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX PH | ||||||||
Address2: |   | ||||||||
City: | CHINLE | ||||||||
State: | AZ | ||||||||
PostalCode: | 865038000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286747166 | ||||||||
FaxNumber: | 9286747705 | ||||||||
Practice Location | |||||||||
Address1: | HWY 191 AND HOSPITAL ROAD | ||||||||
Address2: | CHINLE COMPREHENSIVE HEALTH CARE CENTER | ||||||||
City: | CHINLE | ||||||||
State: | AZ | ||||||||
PostalCode: | 86503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286747166 | ||||||||
FaxNumber: | 9286747705 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2005 | ||||||||
LastUpdateDate: | 03/04/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 42798 | AZ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 35068168 | OH | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 080112518 | 01 | OH | RR MEDICARE | OTHER | 0138872 | 05 | OH |   | MEDICAID |