Provider Demographics
NPI:1891208773
Name:MADDOX, TERRY BENTON III (NP)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:BENTON
Last Name:MADDOX
Suffix:III
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 SOUTHLAKE PARK STE 100
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3608
Mailing Address - Country:US
Mailing Address - Phone:205-987-0724
Mailing Address - Fax:205-987-0725
Practice Address - Street 1:3000 SOUTHLAKE PARK
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3293
Practice Address - Country:US
Practice Address - Phone:205-987-0724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-132264363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health