Provider Demographics
NPI:1447710223
Name:BERRY, MARCUS (NP)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 664
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39205-0664
Mailing Address - Country:US
Mailing Address - Phone:662-213-5784
Mailing Address - Fax:
Practice Address - Street 1:175 EMERY HWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3692
Practice Address - Country:US
Practice Address - Phone:478-803-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903253363LF0000X
GAGAA-NP000383363LP0808X
AL3-001314363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily