MEDICARE: DR. MICHAEL BERRY M.D.

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	G61350	CA

General Provider Information

NPI Number	:	1689670432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL BERRY M.D.

Provider Business Mailing Address
First Line	:	1000 FOWLER WAY
Second Line	:	STE 4
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-5738
Country	:	US
Telephone Number	:	530-626-5421
Fax Number	:	530-626-4265

Provider Business Practice Location Address
First Line	:	1000 FOWLER WAY
Second Line	:	STE 4
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-5738
Country	:	US
Telephone Number	:	530-626-5421
Fax Number	:	530-626-4265

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/08/2007

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