MEDICARE: DR. ADAIR DEBERRY-CARLISLE D.O.

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	208600000X	Surgery Physician	1974	NE
2	2086S0127X	Trauma Surgery Physician	71035-21	WI
3	2086S0127X	Trauma Surgery Physician	1974	NE
4	2086S0127X	Trauma Surgery Physician	6836	OK
5	2086S0127X	Trauma Surgery Physician	007921	AZ
6	208600000X	Surgery Physician	M0050	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P02531927	OTHER	TX	MEDICARE RAIL ROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8AN626	OTHER	TX	BCBSTX
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730110651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADAIR DEBERRY-CARLISLE D.O.

Provider Business Mailing Address
First Line	:	988102 NEBRASKA MEDICAL CENTER
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68198-8102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	630 S FLEISHEL AVE
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-2041
Country	:	US
Telephone Number	:	903-606-5560
Fax Number	:

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	06/02/2025

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Directions to “ DR. ADAIR DEBERRY-CARLISLE D.O.” Practice Location

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