Healthcare Provider Details

I. General information

NPI: 1831816511
Provider Name (Legal Business Name): MICHAEL CONRAD BERRY RCP, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 SOUTH BROADWAY
ST. LOUIS MO
63118-4626
US

IV. Provider business mailing address

7142 CIRCLEVIEW DR.
ST. LOUIS MO
63123-1604
US

V. Phone/Fax

Practice location:
  • Phone: 314-865-7034
  • Fax: 314-865-7018
Mailing address:
  • Phone: 314-452-2115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2004004424
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041494547
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2279G1100X
TaxonomyGeneral Care Registered Respiratory Therapist
License Number100275
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: