Provider Demographics
NPI:1831816511
Name:BERRY, MICHAEL CONRAD (RCP, RN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CONRAD
Last Name:BERRY
Suffix:
Gender:M
Credentials:RCP, RN
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Mailing Address - Street 1:7142 CIRCLEVIEW DR.
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-1604
Mailing Address - Country:US
Mailing Address - Phone:314-452-2115
Mailing Address - Fax:
Practice Address - Street 1:3933 SOUTH BROADWAY
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-4626
Practice Address - Country:US
Practice Address - Phone:314-865-7034
Practice Address - Fax:314-865-7018
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2004004424163W00000X
IL041494547163W00000X
MO1002752279G1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGeneral Care
No163W00000XNursing Service ProvidersRegistered Nurse