1265443048 NPI number — MICHAEL R BERRY CRNA

Table of content: MICHAEL R BERRY CRNA (NPI 1265443048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265443048 NPI number — MICHAEL R BERRY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERRY
Provider First Name:
MICHAEL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

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:
1265443048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 517
Provider Second Line Business Mailing Address:
605 MILLER LANE
Provider Business Mailing Address City Name:
SAINT CLAIR
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56080-0517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 MARSH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANKATO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56001-4752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-345-2623
Provider Business Practice Location Address Fax Number:
507-389-4685
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R139685-2 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 637498000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 967551047349 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2003612 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 436L0BE . This is a "BCBS OF MN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 133973 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP68767 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".




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