Basic Information
| Provider Information | |||||||||
| NPI: | 1740293596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | BRUCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37087 | ||||||||
| Address2: | |||||||||
| City: | BALITMORE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 212973087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286875616 | ||||||||
| FaxNumber: | 8286508076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 COOLIDGE ST | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | GREENEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377435986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236368891 | ||||||||
| FaxNumber: | 4236361732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 06/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | 28732 | NC | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 2083X0100X | 18527 | TN | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1509400 | 05 | TN | MEDICAID |