Basic Information
| Provider Information | |||||||||
| NPI: | 1306835004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEVERANCE | ||||||||
| FirstName: | PERRY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202625131 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25579 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 25579 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 1000006 | 01 | PREFERRED ONE | OTHER | 108496 | 01 | U-CARE | OTHER | 600819 | 01 | ARAZ GRP/AMERICA'S PPO | OTHER | 045098700 | 01 | MEDICAL ASSISTANCE | OTHER | 6D089SE | 01 | BLUE CROSS BLUE SHIELD | OTHER | 449000005 | 01 | MEDICARE | OTHER | HP22744 | 01 | HEALTH PARTNERS | OTHER | 9227216 | 01 | MEDICA HEALTH PLANS | OTHER | 2114131 | 01 | FIRST HEALTH PLAN | OTHER |