Provider Demographics
NPI:1225122690
Name:BERRYHILL, PHILLIP CLAYTON (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:CLAYTON
Last Name:BERRYHILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 EAST GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1075 N. CURTIS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1300
Practice Address - Country:US
Practice Address - Phone:208-367-4000
Practice Address - Fax:208-367-4052
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0523207T00000X
IDM-10837207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30653037Medicaid
NM30653037Medicaid
H90109Medicare UPIN