Basic Information
| Provider Information | |||||||||
| NPI: | 1083788673 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | EZELL | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9735 KINCEY AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280789118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044142870 | ||||||||
| FaxNumber: | 7044142860 | ||||||||
| Practice Location | |||||||||
| Address1: | 1780 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033271116 | ||||||||
| FaxNumber: | 8033276872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 03/31/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 17708 | SC | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | 95-00570 | NC | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 89136H3 | 05 | NC | MEDICAID | 0005525006 | 01 | SC | AETNA | OTHER | 136H3 | 01 | NC | BCBS OF NC | OTHER | 57365 | 01 | SC | MEDCOST | OTHER | 1905786 | 01 | SC | UNITED HEALTHCARE | OTHER | 279866 | 01 | SC | MAMSI | OTHER | 177089 | 05 | SC | MEDICAID | 760694 | 01 | SC | GREAT WEST | OTHER |