1750358685 NPI number — ALLEN D BERRY III MD

Table of content: ALLEN D BERRY III MD (NPI 1750358685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750358685 NPI number — ALLEN D BERRY III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERRY
Provider First Name:
ALLEN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD
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:
1750358685
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1483
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46206-1483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-262-6446
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5959 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-765-2131
Provider Business Practice Location Address Fax Number:
901-765-2064
Provider Enumeration Date:
02/28/2006

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: 207ZP0102X , with the licence number:  15224 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117237001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3046982 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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