Basic Information
| Provider Information | |||||||||
| NPI: | 1609854629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | KEN | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383201734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315841430 | ||||||||
| FaxNumber: | 7315841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383201734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315841430 | ||||||||
| FaxNumber: | 7315841439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 06/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35476 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4067078 | 01 | TN | BCBS-T PROVIDER # | OTHER | 44D-1016448 | 01 | TN | CLIA # | OTHER | 7679503 | 01 | TN | AETNA PROVIDER # | OTHER | 930113436 | 01 | TN | PALMETTO GPA RAILROAD MEDICARE | OTHER |