Provider Demographics
NPI:1609854629
Name:BERRY, KEN D (MD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:D
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 1:30 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38320-1734
Mailing Address - Country:US
Mailing Address - Phone:731-584-1430
Mailing Address - Fax:731-584-1439
Practice Address - Street 1:30 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:TN
Practice Address - Zip Code:38320-1734
Practice Address - Country:US
Practice Address - Phone:731-584-1430
Practice Address - Fax:731-584-1439
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4067078OtherBCBS-T PROVIDER #
TN44D-1016448OtherCLIA #
TN7679503OtherAETNA PROVIDER #
TN930113436OtherPALMETTO GPA RAILROAD MEDICARE
TN44D-1016448OtherCLIA #
TN7679503OtherAETNA PROVIDER #