Basic Information
| Provider Information | |||||||||
| NPI: | 1134380496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TERRY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JEFFERSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3719 DAUPHIN ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513439090 | ||||||||
| FaxNumber: | 2513801015 | ||||||||
| Practice Location | |||||||||
| Address1: | 3290 DAUPHIN ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366064052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516605930 | ||||||||
| FaxNumber: | 2516605931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2008 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | AL30001 | AL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 149810 | 05 | AL | MEDICAID | 511-36669 | 01 | AL | BLUE CROSS BLUE SHEILD OF ALABAMA | OTHER |