Basic Information
| Provider Information | |||||||||
| NPI: | 1609094309 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1990 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703637055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858689300 | ||||||||
| FaxNumber: | 9858510053 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 LAKEWOOD DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | MORGAN CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703801889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9853005438 | ||||||||
| FaxNumber: | 9853801029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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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 | 208600000X | MD.202016 | LA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1178608 | 05 | LA | MEDICAID |