Healthcare Provider Details

I. General information

NPI: 1134212764
Provider Name (Legal Business Name): TERRY L. BERRY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 HOSPITAL DRIVE
OSAGE BEACH MO
65065-3050
US

IV. Provider business mailing address

54 HOSPITAL DRIVE
OSAGE BEACH MO
65065-3050
US

V. Phone/Fax

Practice location:
  • Phone: 573-348-8100
  • Fax: 573-348-8650
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMOR5B53
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberR5B53
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR5B53
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1134212764
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: