Basic Information
| Provider Information | |||||||||
| NPI: | 1952480824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BERRY | ||||||||
| OtherFirstName: | JONATHAN | ||||||||
| OtherMiddleName: | RONALD | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100-15TH AVE. | ||||||||
| Address2: | STE #180 | ||||||||
| City: | SOUTH MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531721160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144222120 | ||||||||
| FaxNumber: | 4144222185 | ||||||||
| Practice Location | |||||||||
| Address1: | S74 W16775 JANESVILLE RD. | ||||||||
| Address2: | |||||||||
| City: | MUSKEGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531507742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144222180 | ||||||||
| FaxNumber: | 4144222185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 11/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301049407 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 30106 | WI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.