Provider Demographics
NPI:1528048626
Name:BERRY, KEVIN (CRNA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3488
Mailing Address - Street 2:DEPT 05-003
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:662-234-7979
Mailing Address - Fax:334-244-1830
Practice Address - Street 1:499 AZALEA DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-234-7979
Practice Address - Fax:334-244-1830
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23133367500000X
MSR798682367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06537247Medicaid