Provider Demographics
NPI:1578537874
Name:LIGHT, TERRY (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:LIGHT
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 1:2160 S FIRST AVE
Mailing Address - Street 2:101-1740, LOYOLA UNIVERSITY MEDICAL CENTER
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-4570
Mailing Address - Fax:708-216-5858
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:101-1740, LOYOLA UNIVERSITY MEDICAL CENTER
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-4570
Practice Address - Fax:708-216-5858
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36060621207XS0106X
IL036060621207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36060621Medicaid
ILL81167Medicare ID - Type Unspecified
IL651590Medicare ID - Type Unspecified
D14357Medicare UPIN
ILK01135Medicare ID - Type Unspecified