Provider Demographics
NPI:1508913849
Name:TERKEURST UROLOGY CLINIC PA
Entity Type:Organization
Organization Name:TERKEURST UROLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE/BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-424-3699
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0428
Mailing Address - Country:US
Mailing Address - Phone:870-424-3699
Mailing Address - Fax:870-424-3707
Practice Address - Street 1:124 HIGHWAY 201 N
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3158
Practice Address - Country:US
Practice Address - Phone:870-424-3699
Practice Address - Fax:870-424-3707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117148002Medicaid
AR117148002Medicaid
AR0479320001Medicare NSC