Provider Demographics
NPI:1083788673
Name:EZELL, TERRY H (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:H
Last Name:EZELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9735 KINCEY AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-9118
Mailing Address - Country:US
Mailing Address - Phone:704-414-2870
Mailing Address - Fax:704-414-2860
Practice Address - Street 1:1780 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1194
Practice Address - Country:US
Practice Address - Phone:803-327-1116
Practice Address - Fax:803-327-6872
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC17708208800000X
NC95-00570208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136H3Medicaid
SC0005525006OtherAETNA
NC136H3OtherBCBS OF NC
SC57365OtherMEDCOST
SC1905786OtherUNITED HEALTHCARE
SC279866OtherMAMSI
SC177089Medicaid
SC760694OtherGREAT WEST
G10095Medicare UPIN
SC57365OtherMEDCOST
NC136H3OtherBCBS OF NC
SC279866OtherMAMSI
SCG100956566Medicare PIN