1083703003 NPI number — DR. THOMAS TERRELL MD

Table of content: DR. THOMAS TERRELL MD (NPI 1083703003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083703003 NPI number — DR. THOMAS TERRELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TERRELL
Provider First Name:
THOMAS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TERRELL
Provider Other First Name:
THOMAS
Provider Other Middle Name:
ROLAND
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1083703003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 EXECUTIVE PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37716-6876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-494-9241
Provider Business Mailing Address Fax Number:
865-494-0895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 EXECUTIVE PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-494-9241
Provider Business Practice Location Address Fax Number:
865-494-0895
Provider Enumeration Date:
10/11/2006

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: 207QS0010X , with the licence number:  038858 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 038858 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1522707 . This is a "MEDICAID PTAN UFP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P00923551 . This is a "RR MEDICARE UFP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1522707 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3373352 . This is a "MEDICARE GRP UFP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 103I083671 . This is a "MEDICARE PTAN UFP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000352900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4278768 . This is a "BCBS TN UFP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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