Provider Demographics
NPI:1720174394
Name:TERRY, MARK W (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:TERRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-4401
Mailing Address - Country:US
Mailing Address - Phone:618-532-5432
Mailing Address - Fax:618-532-1103
Practice Address - Street 1:1415 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-4401
Practice Address - Country:US
Practice Address - Phone:618-532-5432
Practice Address - Fax:618-532-1103
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL557890Medicare ID - Type Unspecified
ILU19287Medicare UPIN