1629209952 NPI number — MICHAEL A BERRY

Table of content: SARAH ROACH PT, DPT (NPI 1275370116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629209952 NPI number — MICHAEL A BERRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL A BERRY
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:
6
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:
1629209952
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1019
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39703-1019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-329-9302
Provider Business Mailing Address Fax Number:
662-328-7597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 BAPTIST BLVD
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39705-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-329-9302
Provider Business Practice Location Address Fax Number:
662-328-7597
Provider Enumeration Date:
08/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BERRY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICAIN/GENERAL SURGEON
Authorized Official Telephone Number:
662-329-9302

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  20632 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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