Provider Demographics
NPI:1376641241
Name:KUSHNER, TERRY K (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:K
Last Name:KUSHNER
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 1:333 N MADISON
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435
Mailing Address - Country:US
Mailing Address - Phone:815-741-7200
Mailing Address - Fax:815-741-7591
Practice Address - Street 1:333 N MADISON
Practice Address - Street 2:PROVENA ST JOSEPH MEDICAL CENTER
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-741-7200
Practice Address - Fax:815-741-7591
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360618272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36061827Medicaid
IL6124854000OtherDEPARTMENT OF LABOR
ILN288949OtherHARMONY
IL9915352OtherBLUE SHIELD
C37551Medicare UPIN
IL36061827Medicaid