Provider Demographics
NPI:1558347377
Name:TERRELL, CALVIN B (MD)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:B
Last Name:TERRELL
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 1:14124 GLENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1591
Mailing Address - Country:US
Mailing Address - Phone:847-918-8863
Mailing Address - Fax:847-918-8864
Practice Address - Street 1:14124 GLENWOOD CT
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1591
Practice Address - Country:US
Practice Address - Phone:847-918-8863
Practice Address - Fax:847-918-8864
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36093355207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36093355Medicaid
ILA91807Medicare UPIN
IL36093355Medicaid