Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | IL |
NPI | 1720174394 |
---|---|
Provider Name | Dr. Mark W Terry |
First Address | Centralia, IL 62801-4401 |
Second Address | Centralia, IL 62801-4401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U19287 | (02) | IL |