Provider Demographics
NPI:1639131592
Name:BERRY, GREG (CPO CPED)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:CPO CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MEDICAL DRIVE
Mailing Address - Street 2:PO BOX 1471
Mailing Address - City:ELIZ CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-338-3002
Mailing Address - Fax:252-338-2902
Practice Address - Street 1:1102 BROWN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889
Practice Address - Country:US
Practice Address - Phone:252-940-1203
Practice Address - Fax:252-940-1206
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO1835222Z00000X, 224P00000X
NC332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7795163OtherINDIVID EDS PED ORTHO
VA9190511Medicaid
NC0482POtherBCBS
7795164OtherINDIVID EDS PED PROSTH
NC7701327Medicaid
VA384410OtherBCBS
VA9190511Medicaid