Basic Information
| Provider Information | |||||||||
| NPI: | 1629477526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BERRY ENTERPRISES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDICAL IQ | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 756 LUCKNEY RD | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390428703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018243255 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Practice Location | |||||||||
| Address1: | 756 LUCKNEY RD | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390428703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018243255 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2014 | ||||||||
| LastUpdateDate: | 08/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | BERRY | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6018243255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.