1588846067 NPI number — JEFFREY G BERRY MD PC

Table of content: (NPI 1588846067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588846067 NPI number — JEFFREY G BERRY MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY G BERRY MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588846067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73083-5366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-826-5960
Provider Business Mailing Address Fax Number:
660-826-4852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 N LEE AVE
Provider Second Line Business Practice Location Address:
SUITE 236
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73103-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-524-4105
Provider Business Practice Location Address Fax Number:
405-235-0738
Provider Enumeration Date:
11/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERRY
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
405-524-4105

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DN8773 . This is a "RR MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 612969700 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200127640A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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