Provider Demographics
NPI:1982640264
Name:BERRY, SUSAN AMELIA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:AMELIA
Last Name:BERRY
Suffix:
Gender:F
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE, MMC 75
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-624-5965
Mailing Address - Fax:612-626-2993
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:516 DELAWARE STREET SE, PWB FOURTH FLOOR, ROOM 4-100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26368207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN666773200Medicaid
MN24479OtherARAZ
MT0052275Medicaid
MN12-24753OtherMEDICA CHOICE
MN1270280OtherMEDICA PRIMARY
NE41184394337Medicaid
WI30580800Medicaid
MN1010201OtherPREFERRED ONE
IA1990358Medicaid
MN100978OtherUCARE
MN2T262BEOtherBCBS
MNHP12898OtherHEALTHPARTNERS
MN370010896Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MN370001027Medicare ID - Type UnspecifiedMN MEDICARE
MN1010201OtherPREFERRED ONE