1023477536 NPI number — WHITNEY BROOKE TERRY PA

Table of content: WHITNEY BROOKE TERRY PA (NPI 1023477536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023477536 NPI number — WHITNEY BROOKE TERRY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TERRY
Provider First Name:
WHITNEY
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023477536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-560-4304
Provider Business Mailing Address Fax Number:
864-560-4413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 SERPENTINE DR STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-560-6717
Provider Business Practice Location Address Fax Number:
864-560-7105
Provider Enumeration Date:
02/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  2955 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: TL3012 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SCD2697628 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 3675PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5542034 . This is a "BCBS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: Q020109 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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