Provider Demographics
NPI:1205813094
Name:MASON, TERRY (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:MASON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 S WABASH AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2955
Mailing Address - Country:US
Mailing Address - Phone:312-842-4400
Mailing Address - Fax:312-842-4595
Practice Address - Street 1:2850 S WABASH AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2955
Practice Address - Country:US
Practice Address - Phone:312-842-4400
Practice Address - Fax:312-842-4595
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059147208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059147Medicaid
IL01621679OtherBCBS OF IL
ILD 15213Medicare UPIN