1649228446 NPI number — MARK A TERRY MD

Table of content: MARK A TERRY MD (NPI 1649228446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649228446 NPI number — MARK A TERRY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TERRY
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
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:
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:
1649228446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
531 4TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83501-2450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-743-4393
Provider Business Mailing Address Fax Number:
208-743-4214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-799-5335
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2006

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: 2085R0205X , with the licence number:  MD00017547 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0227614 . This is a "DLI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00468202 . This is a "TRAVELERS/RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8255408 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003973900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77142 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010165165 . This is a "REGENCE BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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