Provider Demographics
NPI:1093043101
Name:BERRY, CRAIG
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 LAMPLIGHTER LN
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9314
Mailing Address - Country:US
Mailing Address - Phone:262-573-1657
Mailing Address - Fax:
Practice Address - Street 1:920 LAMPLIGHTER LN
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9314
Practice Address - Country:US
Practice Address - Phone:262-573-1657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41733700332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41733700Medicaid