Provider Demographics
NPI:1295867968
Name:DR. GREGORY K. TERPSTRA D.O., FAMILY PRACTICE, L.L.C.
Entity Type:Organization
Organization Name:DR. GREGORY K. TERPSTRA D.O., FAMILY PRACTICE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WILMA
Authorized Official - Middle Name:
Authorized Official - Last Name:TERPSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-438-3660
Mailing Address - Street 1:612 E HIGH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-1426
Mailing Address - Country:US
Mailing Address - Phone:573-438-3660
Mailing Address - Fax:573-438-1140
Practice Address - Street 1:612 E HIGH ST STE 210
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1426
Practice Address - Country:US
Practice Address - Phone:573-438-3660
Practice Address - Fax:573-438-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110137261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000006721Medicare ID - Type Unspecified
MOF57275Medicare UPIN