Provider Demographics
NPI:1952439705
Name:BERRY, TIMOTHY BRYAN (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BRYAN
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 1:740 TELL ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-5169
Mailing Address - Country:US
Mailing Address - Phone:423-745-2676
Mailing Address - Fax:
Practice Address - Street 1:740 TELL ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-5169
Practice Address - Country:US
Practice Address - Phone:423-745-2676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG79200Medicare UPIN