Provider Demographics
NPI:1285722579
Name:THOMAS K BERRY MD PC
Entity type:Organization
Organization Name:THOMAS K BERRY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-634-5003
Mailing Address - Street 1:314 FAIRY STREET EXT
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1913
Mailing Address - Country:US
Mailing Address - Phone:276-634-5003
Mailing Address - Fax:276-634-5017
Practice Address - Street 1:314 FAIRY STREET EXT
Practice Address - Street 2:SUITE B
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1913
Practice Address - Country:US
Practice Address - Phone:276-634-5003
Practice Address - Fax:276-634-5017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10381172OtherCAQH
VA007300018Medicaid
VA216612OtherANTHEM
VAB05542Medicare UPIN
VA020001456Medicare ID - Type UnspecifiedMEDICARE
VAC08438Medicare PIN