=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982640264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN AMELIA BERRY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2006
-----------------------------------------------------
Last Update Date | 04/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | UNIVERSITY OF MINNESOTA PHYSICIANS 516 DELAWARE STREET SE, PWB FOURTH FLOOR, ROOM 4-100
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-626-6777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | UNIVERSITY OF MINNESOTA PHYSICIANS 420 DELAWARE STREET SE, MMC 75
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-624-5965
-----------------------------------------------------
Fax | 612-626-2993
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207SG0201X
-----------------------------------------------------
Taxonomy Name | Clinical Genetics (M.D.) Physician
-----------------------------------------------------
License Number | 26368
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 26368
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------