Basic Information
| Provider Information | |||||||||
| NPI: | 1366527137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREA | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3023 DAVENPORT AVE | ||||||||
| Address2: | P O BOX 3272 | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486023652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897939830 | ||||||||
| FaxNumber: | 9897974077 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 COOPER AVE | ||||||||
| Address2: | 900 BLDG | ||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895834401 | ||||||||
| FaxNumber: | 9895834409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 02685272 | 01 | MI | HP | OTHER | 104634636 | 05 | MI | MEDICAID | P00265524 | 01 | MI | RAILROAD MR # | OTHER | 0207310972 | 01 | MI | BLUE CROSS BLUE SHIELD # | OTHER |