Basic Information
| Provider Information | |||||||||
| NPI: | 1942705587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45652 WHITE PINES DR | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483743745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488942948 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2800 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084226200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2018 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 036.157777 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.