Provider Demographics
NPI:1932189255
Name:BERRY, GERARD THOMAS SR (MD)
Entity Type:Individual
Prefix:PROF
First Name:GERARD
Middle Name:THOMAS
Last Name:BERRY
Suffix:SR
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 1:3 BLACKFAN CIR
Mailing Address - Street 2:SUITE 14070
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5713
Mailing Address - Country:US
Mailing Address - Phone:617-355-4316
Mailing Address - Fax:617-730-4874
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:BOSTON CHILDREN'S HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-857-4636
Practice Address - Fax:617-730-4874
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD018408E207SG0201X
MA230307207SG0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
BE117913OtherBLUE SHIELD
PA0008577400005Medicaid
3786201OtherUSHC
BE117913OtherBLUE SHIELD
PA0008577400005Medicaid