Provider Demographics
NPI:1306828579
Name:BERRY, TANIA LYNN (DO)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:LYNN
Last Name:BERRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BRONSON
Mailing Address - State:MI
Mailing Address - Zip Code:49028-1213
Mailing Address - Country:US
Mailing Address - Phone:517-369-2506
Mailing Address - Fax:517-369-2376
Practice Address - Street 1:197 DIVISION ST
Practice Address - Street 2:
Practice Address - City:BRONSON
Practice Address - State:MI
Practice Address - Zip Code:49028-1213
Practice Address - Country:US
Practice Address - Phone:517-369-2506
Practice Address - Fax:517-369-2376
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013815207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0151200195OtherBLUECROSS
MI0131300OtherPHP/IBA
MI4315160Medicaid
MI0N29870Medicare ID - Type Unspecified
MI0131300OtherPHP/IBA