1659358315 NPI number — MR. PETER R BERRY

Table of content: MR. PETER R BERRY (NPI 1659358315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659358315 NPI number — MR. PETER R BERRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERRY
Provider First Name:
PETER
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1659358315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 FM 2181
Provider Second Line Business Mailing Address:
#300
Provider Business Mailing Address City Name:
HICKORY CREEK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75065-7636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-321-1311
Provider Business Mailing Address Fax Number:
940-497-1374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1017 EAST TRINITY MILLS RD.
Provider Second Line Business Practice Location Address:
STE. 120
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75006-1458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-466-0528
Provider Business Practice Location Address Fax Number:
972-466-2345
Provider Enumeration Date:
12/23/2005

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: 237700000X , with the licence number:  20246 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 177663501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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