Provider Demographics
NPI:1982673505
Name:BERRY, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
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 1:5770 SOUTH 250 EAST
Mailing Address - Street 2:SUITE 135
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8241
Mailing Address - Country:US
Mailing Address - Phone:801-314-2225
Mailing Address - Fax:801-314-2345
Practice Address - Street 1:5770 SOUTH 250 EAST
Practice Address - Street 2:SUITE 135
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-8241
Practice Address - Country:US
Practice Address - Phone:801-314-2225
Practice Address - Fax:801-314-2345
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT181781-8905207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE27814Medicare UPIN
UT000004883Medicare ID - Type Unspecified