Provider Demographics
NPI:1659390490
Name:TERRY, PETER JOHN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:TERRY
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 1:11855 ULYSSES ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3947
Mailing Address - Country:US
Mailing Address - Phone:763-785-4200
Mailing Address - Fax:763-785-8419
Practice Address - Street 1:11855 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3947
Practice Address - Country:US
Practice Address - Phone:763-785-4200
Practice Address - Fax:763-785-8419
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN556T0TEOtherBLUE CROSS BLUE SHIELD
MNG94363Medicare UPIN
MN080013840Medicare ID - Type UnspecifiedMEDICARE