Provider Demographics
NPI:1831322528
Name:ROBERT E. BERRY, DO PA
Entity Type:Organization
Organization Name:ROBERT E. BERRY, DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:858-571-0606
Mailing Address - Street 1:5471 KEARNY VILLA RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1151
Mailing Address - Country:US
Mailing Address - Phone:858-571-0606
Mailing Address - Fax:858-715-4942
Practice Address - Street 1:5471 KEARNY VILLA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1151
Practice Address - Country:US
Practice Address - Phone:858-571-0606
Practice Address - Fax:858-715-4942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1511207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A4043Medicare PIN
6250630002Medicare NSC