Provider Demographics
NPI:1417173717
Name:TERRY EBERT, MD, INC
Entity Type:Organization
Organization Name:TERRY EBERT, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:EBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-1050
Mailing Address - Street 1:509 RIDGE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1643
Mailing Address - Country:US
Mailing Address - Phone:219-836-1050
Mailing Address - Fax:219-836-4969
Practice Address - Street 1:509 RIDGE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1643
Practice Address - Country:US
Practice Address - Phone:219-836-1050
Practice Address - Fax:219-836-4969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022150A261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01022150AOtherPHYSICIAN LICENSE NUMBER
IN50001124AOtherCORPORATION REGISTRATION
IN50001124AOtherCORPORATION REGISTRATION
IN50001124AOtherCORPORATION REGISTRATION
INAE6711926OtherDEA REGISTRATION NUMBER