Basic Information
| Provider Information | |||||||||
| NPI: | 1467421495 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 TURWILL LN | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490064231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693438170 | ||||||||
| FaxNumber: | 2693822388 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 TURWILL LN | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490064231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693438170 | ||||||||
| FaxNumber: | 2693822388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 10/16/2014 | ||||||||
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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 | 207X00000X | 4301038754 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2864753 | 05 | MI | MEDICAID | 1467421495 | 05 | MI | MEDICAID |