Healthcare Provider Details

I. General information

NPI: 1124175013
Provider Name (Legal Business Name): BARRY BERCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5050
  • Fax:
Mailing address:
  • Phone: 601-984-2940
  • Fax: 601-984-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number32773
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number20556
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: