Provider Demographics
NPI:1639286446
Name:TERRY TYLER MD PC
Entity Type:Organization
Organization Name:TERRY TYLER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:N
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-375-6224
Mailing Address - Street 1:2243 MAIN AVE
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4699
Mailing Address - Country:US
Mailing Address - Phone:970-375-6224
Mailing Address - Fax:970-259-2431
Practice Address - Street 1:2243 MAIN AVE
Practice Address - Street 2:SUITE 3A
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4699
Practice Address - Country:US
Practice Address - Phone:970-375-6224
Practice Address - Fax:970-259-2431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31498102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC806772Medicare PIN