Provider Demographics
NPI:1124192141
Name:BERRYMAN, SALLY M (MD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:M
Last Name:BERRYMAN
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 1:1600 N GRAND AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2700
Mailing Address - Country:US
Mailing Address - Phone:719-543-4000
Mailing Address - Fax:719-543-1041
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2700
Practice Address - Country:US
Practice Address - Phone:719-543-4000
Practice Address - Fax:719-543-1041
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28181207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO77306732Medicaid
CO77306732Medicaid