Basic Information
| Provider Information | |||||||||
| NPI: | 1407932411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TERRY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4947 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312084947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783012362 | ||||||||
| FaxNumber: | 4783012272 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783014111 | ||||||||
| FaxNumber: | 4783015812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/18/2014 | ||||||||
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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 | 207RN0300X | 014578 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 390005316 | 01 | GA | RAILROAD MEDICARE | OTHER | 000064281F | 05 | GA | MEDICAID |