Basic Information
| Provider Information | |||||||||
| NPI: | 1194943522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 2 BOX 615A | ||||||||
| Address2: | |||||||||
| City: | SCARBRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259179784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043882525 | ||||||||
| FaxNumber: | 3043882537 | ||||||||
| Practice Location | |||||||||
| Address1: | RR 2 BOX 615A | ||||||||
| Address2: | |||||||||
| City: | SCARBRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259179784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043882525 | ||||||||
| FaxNumber: | 3043882537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 12/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2120 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 34.012389 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0181970 | 05 | OH | MEDICAID | 3810010455 | 05 | WV | MEDICAID |