Healthcare Provider Details

I. General information

NPI: 1225000409
Provider Name (Legal Business Name): PAUL ALBERT BERRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: PAUL A BERRY

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 NICOLLET AVE S MAIL STOP 31500A
BLOOMINGTON MN
55420-2824
US

IV. Provider business mailing address

8100 34TH AVE S
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 952-887-6600
  • Fax: 952-886-7015
Mailing address:
  • Phone: 952-883-5790
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27806
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: