Healthcare Provider Details

I. General information

NPI: 1023168549
Provider Name (Legal Business Name): MICHAEL K BERRY MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PROSPECT PL
CORONADO CA
92118-1943
US

IV. Provider business mailing address

PO BOX 28247
TEMPE AZ
85285-8247
US

V. Phone/Fax

Practice location:
  • Phone: 619-522-3722
  • Fax:
Mailing address:
  • Phone: 480-967-6500
  • Fax: 480-967-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG072558
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL K BERRY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 480-967-6500