MEDICARE: BERRY MEDICAL CARE, PLLC

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	208D00000X	General Practice Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1659764850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERRY MEDICAL CARE, PLLC

Provider Business Mailing Address
First Line	:	4201 E BERRY ST
Second Line	:	STE 15
City	:	FORT WORTH
State	:	TX
Zip	:	76105-5053
Country	:	US
Telephone Number	:	817-535-8200
Fax Number	:	817-535-8207

Provider Business Practice Location Address
First Line	:	4201 E BERRY ST
Second Line	:	STE 15
City	:	FORT WORTH
State	:	TX
Zip	:	76105-5053
Country	:	US
Telephone Number	:	817-535-8200
Fax Number	:	817-535-8207

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	MICHELE GRAHAM
Credential	:
Telephone Number	:	972-245-1315

Provider Enumeration Date	:	03/12/2015
Last Update Date	:	03/12/2015

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