Provider Demographics
NPI:1073501383
Name:BERRY, THOMAS K (MD PC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:K
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 FAIRY STREET EXT
Mailing Address - Street 2:STE 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:STE 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042317208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10381172OtherCAQH
VA7300018Medicaid
VA5297564OtherAETNA
216612OtherANTHEM
VAC08438OtherMEDICARE PIN
B05542Medicare UPIN
VAC08438Medicare PIN