Provider Demographics
NPI:1205253267
Name:BERRY, SHANNON (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
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 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-8211
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7500
Practice Address - Fax:503-494-4997
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD173846207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine