Healthcare Provider Details

I. General information

NPI: 1336567007
Provider Name (Legal Business Name): TOMMIE RUSSELL BERRY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-3646
  • Fax:
Mailing address:
  • Phone: 215-707-3646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number35.137255
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number89500
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number35.137255
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number85696
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD486652
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: