Provider Demographics
NPI:1316046469
Name:BERRY, ELAINE K (MD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:K
Last Name:BERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022-1936
Mailing Address - Country:US
Mailing Address - Phone:712-243-2850
Mailing Address - Fax:712-243-7423
Practice Address - Street 1:1501 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1936
Practice Address - Country:US
Practice Address - Phone:712-243-2850
Practice Address - Fax:712-243-7423
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3032763Medicaid
IA03448Medicare PIN
IA3032763Medicaid