Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 036127202 | IL |
N | 207X00000X | Orthopaedic Surgeon | 39450 | IA |
N | 207XS0117X | Orthopaedic Spine Surgeon | 036127202 | IL |
N | 207XS0117X | Orthopaedic Spine Surgeon | 39450 | IA |
NPI | 1114121969 |
---|---|
Provider Name | Michael Richard Berry |
First Address | Moline, IL 61265-6194 |
Second Address | Moline, IL 61265-6194 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2007 |
Last Update Date | 15/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
209395016 | MEDICARE PTAN (01) | IL |
578210011 | MEDICARE PTAN (01) | IA |