Basic Information
| Provider Information | |||||||||
| NPI: | 1124192141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRYMAN | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N GRAND AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195434000 | ||||||||
| FaxNumber: | 7195431041 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 N GRAND AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195434000 | ||||||||
| FaxNumber: | 7195431041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 28181 | CO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 77306732 | 05 | CO | MEDICAID |