Provider Demographics
NPI:1336567007
Name:BERRY, TOMMIE RUSSELL JR (MD)
Entity Type:Individual
Prefix:MR
First Name:TOMMIE
Middle Name:RUSSELL
Last Name:BERRY
Suffix:JR
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:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2030 STRINGTOWN RD
Practice Address - Street 2:STE 200
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123
Practice Address - Country:US
Practice Address - Phone:614-533-5500
Practice Address - Fax:614-533-0103
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.137255208100000X, 2081S0010X
SC856962081S0010X
GA895002081S0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program