Provider Demographics
NPI:1043450208
Name:TERRY L SHIPE MD LLC
Entity Type:Organization
Organization Name:TERRY L SHIPE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHIPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-665-7595
Mailing Address - Street 1:306 E MAUMEE ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-2035
Mailing Address - Country:US
Mailing Address - Phone:260-665-7595
Mailing Address - Fax:260-665-6586
Practice Address - Street 1:306 E MAUMEE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-2035
Practice Address - Country:US
Practice Address - Phone:260-665-7595
Practice Address - Fax:260-665-6586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029019207L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100329370AMedicaid
IN770760Medicare PIN