Basic Information
| Provider Information | |||||||||
| NPI: | 1205330578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | MATS | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 46 GARDNER ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021502129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814753312 | ||||||||
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| Practice Location | |||||||||
| Address1: | 51 BLOSSOM ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177223000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2018 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | RN2264496 | MA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 363LP0200X | RN2264496 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.