Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 02001985A | IN |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 02001985A | IN |
NPI | 1760591648 |
---|---|
Provider Name | Kevin Terrell |
First Address | Chicago, IL 60677-5383 |
Second Address | Columbus, IN 47201 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 03/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000112255 | ANTHEM (01) | IN |
200215910 | (05) | IN |
G95430 | (02) |