Provider Demographics
NPI:1083703003
Name:TERRELL, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:TERRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:ROLAND
Other - Last Name:TERRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:110 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-6876
Mailing Address - Country:US
Mailing Address - Phone:865-494-9241
Mailing Address - Fax:865-494-0895
Practice Address - Street 1:110 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716
Practice Address - Country:US
Practice Address - Phone:865-494-9241
Practice Address - Fax:865-494-0895
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN038858207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522707OtherMEDICAID PTAN UFP
TNP00923551OtherRR MEDICARE UFP
TN1522707Medicaid
TN3373352OtherMEDICARE GRP UFP
TN103I083671OtherMEDICARE PTAN UFP
FL000352900Medicaid
TN4278768OtherBCBS TN UFP
TN4278768OtherBCBS TN UFP
TN103I083671OtherMEDICARE PTAN UFP