Provider Demographics
NPI:1871730036
Name:BERRY, LYLE M (MD)
Entity type:Individual
Prefix:
First Name:LYLE
Middle Name:M
Last Name:BERRY
Suffix:
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-408-6220
Mailing Address - Fax:
Practice Address - Street 1:8TH AVE. & C ST.
Practice Address - Street 2:LDS/IMC HOSPITALIST GROUP
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-0001
Practice Address - Country:US
Practice Address - Phone:801-408-5482
Practice Address - Fax:801-408-5481
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7471625-1205208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000074452Medicare PIN