Basic Information
| Provider Information | |||||||||
| NPI: | 1528113412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONDESSY | ||||||||
| FirstName: | TERRENCE | ||||||||
| MiddleName: | MERLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 HASKINS RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434021637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193537069 | ||||||||
| FaxNumber: | 4193537076 | ||||||||
| Practice Location | |||||||||
| Address1: | 838 E WOOSTER ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434023186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193722271 | ||||||||
| FaxNumber: | 4193543222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-050793 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0616962 | 05 | OH | MEDICAID |