Healthcare Provider Details

I. General information

NPI: 1982640264
Provider Name (Legal Business Name): SUSAN AMELIA BERRY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF MINNESOTA PHYSICIANS 516 DELAWARE STREET SE, PWB FOURTH FLOOR, ROOM 4-100
MINNEAPOLIS MN
55455
US

IV. Provider business mailing address

UNIVERSITY OF MINNESOTA PHYSICIANS 420 DELAWARE STREET SE, MMC 75
MINNEAPOLIS MN
55455
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-6777
  • Fax:
Mailing address:
  • Phone: 612-624-5965
  • Fax: 612-626-2993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number26368
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26368
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: