Basic Information
Provider Information | |||||||||
NPI: | 1538546585 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TERRELL | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | JEANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LUSKEY | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | JEANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | UNC DEPARTMENT OF PEDIATRICS UNC SOM | ||||||||
Address2: | 260 MACNIDER BUILDING, CB#7220 | ||||||||
City: | CHAPEL HILL | ||||||||
State: | NC | ||||||||
PostalCode: | 275997220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9199661505 | ||||||||
FaxNumber: | 9199667299 | ||||||||
Practice Location | |||||||||
Address1: | UNC DEPARTMENT OF PEDIATRICS UNC SOM | ||||||||
Address2: | 260 MACNIDER BUILDING, CB#7220 | ||||||||
City: | CHAPEL HILL | ||||||||
State: | NC | ||||||||
PostalCode: | 275997220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9199661505 | ||||||||
FaxNumber: | 9199667299 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/29/2015 | ||||||||
LastUpdateDate: | 04/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 209432 | NC | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.