MEDICARE: DR. DIANE MAE JEROME BARRY DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3422	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	231957	OTHER	MN	CHIROCARE
2	44-42579	OTHER	MN	MEDICA
3	53971700	OTHER	MN	MEDICAL ASSISTANCE
4	0140	OTHER	MN	HEA;TH SERVICE MANAGEMENT
5	5C183JE	OTHER	MN	B:UE CROSS

General Provider Information

NPI Number	:	1396841540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE MAE JEROME BARRY DC

Provider Business Mailing Address
First Line	:	12450 UPPER HEATHER AVE N
Second Line	:
City	:	HUGO
State	:	MN
Zip	:	55038-8310
Country	:	US
Telephone Number	:	651-429-4047
Fax Number	:

Provider Business Practice Location Address
First Line	:	1526 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2227
Country	:	US
Telephone Number	:	651-690-9366
Fax Number	:	651-690-4736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	03/06/2019

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