Provider Demographics
NPI:1104830876
Name:BERRY, THOMAS L (NP)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:L
Last Name:BERRY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 FRESNO LN
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2840
Mailing Address - Country:US
Mailing Address - Phone:708-957-9121
Mailing Address - Fax:
Practice Address - Street 1:7850 W COLLEGE DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1010
Practice Address - Country:US
Practice Address - Phone:708-361-6990
Practice Address - Fax:708-361-7697
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005729363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209005729Medicaid
ILP00792110OtherRR MEDICARE PTAN
ILP00792110OtherRR MEDICARE PTAN
IL211968003Medicare PIN
IL211968006Medicare PIN