Provider Demographics
NPI:1811987761
Name:BERRY E WINN MD PLLC
Entity type:Organization
Organization Name:BERRY E WINN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BERRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WINN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-781-9466
Mailing Address - Street 1:LOCKBOX #17
Mailing Address - Street 2:2424 E. 21ST #100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1711
Mailing Address - Country:US
Mailing Address - Phone:866-321-8433
Mailing Address - Fax:
Practice Address - Street 1:300 ROCKEFELLER DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-5075
Practice Address - Country:US
Practice Address - Phone:918-781-9466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100747830AMedicaid
OK100747830AMedicaid