Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 036107605 | IL |
N | 207PE0004X | Emergency Medical Services | 036107605 | IL |
NPI | 1194755587 |
---|---|
Provider Name | Jude Perez |
First Address | Rockford, IL 61114-4937 |
Second Address | Rockford, IL 61114-4937 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2006 |
Last Update Date | 20/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
36107605 | (05) | IL |
F67715 | (02) |