Provider Demographics
NPI:1912111006
Name:EDWARD W. BERRY MD PC
Entity Type:Organization
Organization Name:EDWARD W. BERRY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-387-3900
Mailing Address - Street 1:1652 WILDCAT LN # 1
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3236
Mailing Address - Country:US
Mailing Address - Phone:801-393-2249
Mailing Address - Fax:801-393-9909
Practice Address - Street 1:4403 HARRISON BLVD STE 3680
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3289
Practice Address - Country:US
Practice Address - Phone:801-387-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT498622472004Medicaid
E61533Medicare UPIN
UT498622472004Medicaid