Provider Demographics
NPI:1639151160
Name:BERRYHILL MEDICAL PL
Entity Type:Organization
Organization Name:BERRYHILL MEDICAL PL
Other - Org Name:BERRYHILL MEDICAL PLAZA LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:VERNALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-476-9691
Mailing Address - Street 1:4785 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2497
Mailing Address - Country:US
Mailing Address - Phone:850-476-9691
Mailing Address - Fax:850-476-0777
Practice Address - Street 1:4785 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2497
Practice Address - Country:US
Practice Address - Phone:850-476-9691
Practice Address - Fax:850-476-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65994207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258620701Medicaid
FL258620700Medicaid
FL59083579OtherBCBS AL
FL45147OtherBC BS FL
FL258620700Medicaid
FL=========OtherFIRST HEALTH
FL=========OtherHUMANA
FL=========OtherVISTA
FL258620700Medicaid
FL=========OtherHORIZON
FL=========OtherCIGNA
FLK0876Medicare ID - Type UnspecifiedMEDICARE GROUP
FL45147OtherBC BS FL
FL=========OtherMULTIPLAN
FL=========OtherBEECHSTREET
FL258620701Medicaid