Provider Demographics
NPI:1578516308
Name:TYRRELL, TERRENCE A (MD)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:A
Last Name:TYRRELL
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 1:301 WEST LINCOLN STREET
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220
Mailing Address - Country:US
Mailing Address - Phone:618-235-0955
Mailing Address - Fax:618-235-9203
Practice Address - Street 1:180 SOUTH THIRD STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220
Practice Address - Country:US
Practice Address - Phone:618-235-0651
Practice Address - Fax:618-235-9722
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR56202085R0202X
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
L95010OtherMEDICARE PIN
141553OtherHEALTHLINK
P04405Medicare PIN
141553OtherHEALTHLINK