Provider Demographics
NPI:1104895614
Name:BERRY, EMMETT REAVES (MD)
Entity type:Individual
Prefix:DR
First Name:EMMETT
Middle Name:REAVES
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3888 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2417
Mailing Address - Country:US
Mailing Address - Phone:478-477-4044
Mailing Address - Fax:478-477-7076
Practice Address - Street 1:3888 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2417
Practice Address - Country:US
Practice Address - Phone:478-477-4044
Practice Address - Fax:478-477-7076
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023905208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics