Basic Information
| Provider Information | |||||||||
| NPI: | 1811987761 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BERRY E WINN MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | LOCKBOX #17 | ||||||||
| Address2: | 2424 E. 21ST #100 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741141711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663218433 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 ROCKEFELLER DR | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744015075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187819466 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 10/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | WINN | ||||||||
| AuthorizedOfficialFirstName: | BERRY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9187819466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 100747830A | 05 | OK | MEDICAID |