Basic Information
| Provider Information | |||||||||
| NPI: | 1528274842 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3016 W CHARLESTON BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026715150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1707 W CHARLESTON BLVD STE 160 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026715150 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MED-PHYS-LIC-51952 | MT | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MT188337 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 19452 | NV | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.