Provider Demographics
NPI:1194702795
Name:BERRY, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6801 34TH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-5591
Mailing Address - Country:US
Mailing Address - Phone:708-484-8400
Mailing Address - Fax:708-484-8426
Practice Address - Street 1:6801 34TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-5591
Practice Address - Country:US
Practice Address - Phone:708-484-8400
Practice Address - Fax:708-484-8426
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036092197207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092197Medicaid
IL036092197Medicaid