Provider Demographics
NPI:1720124217
Name:BERRY, KEVIN R (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:614-221-7372
Mailing Address - Fax:614-221-5613
Practice Address - Street 1:7277 SMITHS MILL RD
Practice Address - Street 2:SUITE # 250
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-8195
Practice Address - Country:US
Practice Address - Phone:614-221-7372
Practice Address - Fax:614-221-5613
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048752207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0565517Medicaid
OH0565517Medicaid
OHA16307Medicare UPIN