=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841314994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARD S. BERRY MDPC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8441 149TH AVE
-----------------------------------------------------
City | HOWARD BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11414-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-845-1919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8441 149TH AVE
-----------------------------------------------------
City | HOWARD BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11414-1218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICAHRD S BERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-845-1919
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 124011
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------