Provider Demographics
NPI:1770553521
Name:BERRY, ALPHONSO (MD)
Entity type:Individual
Prefix:
First Name:ALPHONSO
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 1:23550 HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2614
Mailing Address - Country:US
Mailing Address - Phone:248-381-8081
Mailing Address - Fax:734-402-0254
Practice Address - Street 1:23550 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-2614
Practice Address - Country:US
Practice Address - Phone:248-381-8081
Practice Address - Fax:734-402-0254
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4605652Medicaid
MI4605652Medicaid