Provider Demographics
NPI:1154742716
Name:PAUL R BERRY
Entity type:Organization
Organization Name:PAUL R BERRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-266-0424
Mailing Address - Street 1:103 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-2372
Mailing Address - Country:US
Mailing Address - Phone:203-270-0330
Mailing Address - Fax:203-270-0330
Practice Address - Street 1:103 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2372
Practice Address - Country:US
Practice Address - Phone:203-270-0330
Practice Address - Fax:203-270-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001915225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D300006377Medicare PIN