Provider Demographics
NPI:1487653861
Name:BERRY, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:BERRY
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 1:380 MERRIMACK ST
Mailing Address - Street 2:STE. 2D
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-5870
Mailing Address - Country:US
Mailing Address - Phone:978-794-0234
Mailing Address - Fax:978-794-0560
Practice Address - Street 1:380 MERRIMACK ST
Practice Address - Street 2:STE. 2D
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-5870
Practice Address - Country:US
Practice Address - Phone:978-794-0234
Practice Address - Fax:978-794-0560
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48471207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0153109Medicaid
NH30006739Medicaid
MAD24023Medicare PIN
MAD24023Medicare ID - Type Unspecified
MA0153109Medicaid
NHRE8532Medicare PIN