Provider Demographics
NPI:1639139884
Name:TERRY, JOSEPH G (PT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:G
Last Name:TERRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 N CUMMINGS LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9646
Mailing Address - Country:US
Mailing Address - Phone:309-444-1030
Mailing Address - Fax:309-444-1060
Practice Address - Street 1:850 43RD AVE STE 100
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-8401
Practice Address - Country:US
Practice Address - Phone:309-743-2070
Practice Address - Fax:309-743-2073
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070008578225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23376Medicare ID - Type Unspecified