Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081S0010X | Sports Medicine | 85696 | SC |
N | 213ES0000X | Sports Medicine | 85696 | SC |
Y | 2081S0010X | Sports Medicine | 89500 | GA |
Y | 213ES0000X | Sports Medicine | 89500 | GA |
NPI | 1336567007 |
---|---|
Provider Name | Mr. Tommie Russell Berry JR. |
First Address | Akron, OH 44310-3110 |
Second Address | Gainesville, GA 30501-3854 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2014 |
Last Update Date | 30/07/2021 |