Basic Information
Provider Information | |||||||||
NPI: | 1861653404 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EVERHART | ||||||||
FirstName: | TERRY | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 12622 | ||||||||
Address2: |   | ||||||||
City: | BELFAST | ||||||||
State: | ME | ||||||||
PostalCode: | 049154017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4434816480 | ||||||||
FaxNumber: | 4434816515 | ||||||||
Practice Location | |||||||||
Address1: | 3169 BRAVERTON STREET | ||||||||
Address2: | SUITE 201 | ||||||||
City: | EDGEWATER | ||||||||
State: | MD | ||||||||
PostalCode: | 210372690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109564911 | ||||||||
FaxNumber: | 4109564935 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2008 | ||||||||
LastUpdateDate: | 04/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2010-01890 | NC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 149428 | NC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | D72318 | MD | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 043456600 | 05 | MD |   | MEDICAID | 97518901 | 01 | MD | BCBS | OTHER | K6430005 | 01 | DC | BCBS | OTHER | 9140763 | 01 | MD | AETNA PPO | OTHER | 8082731 | 01 | MD | AETNA HMO | OTHER |