Provider Demographics
NPI:1588846067
Name:JEFFREY G BERRY MD PC
Entity Type:Organization
Organization Name:JEFFREY G BERRY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-524-4105
Mailing Address - Street 1:PO BOX 5366
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-5366
Mailing Address - Country:US
Mailing Address - Phone:660-826-5960
Mailing Address - Fax:660-826-4852
Practice Address - Street 1:1111 N LEE AVE
Practice Address - Street 2:SUITE 236
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2600
Practice Address - Country:US
Practice Address - Phone:405-524-4105
Practice Address - Fax:405-235-0738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDN8773OtherRR MEDICARE
OK612969700OtherUS DEPT OF LABOR
OK200127640AMedicaid
OK612969700OtherUS DEPT OF LABOR