Basic Information
Provider Information | |||||||||
NPI: | 1760591648 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TERRELL | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 775383 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606775383 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123765315 | ||||||||
FaxNumber: | 8123753477 | ||||||||
Practice Location | |||||||||
Address1: | 2630 22ND ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | IN | ||||||||
PostalCode: | 47201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123753784 | ||||||||
FaxNumber: | 8123753781 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 10/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 02001985A | IN | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207QA0401X | 02001985A | IN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | 000000112255 | 01 | IN | ANTHEM | OTHER | 200215910 | 05 | IN |   | MEDICAID |