Provider Demographics
NPI:1750359030
Name:PHILLIS, TERRY M JR (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:M
Last Name:PHILLIS
Suffix:JR
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:PO BOX 428
Mailing Address - Street 2:622 LEIGHTON AVE
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207
Mailing Address - Country:US
Mailing Address - Phone:256-237-6717
Mailing Address - Fax:256-236-1920
Practice Address - Street 1:622 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207
Practice Address - Country:US
Practice Address - Phone:256-237-6717
Practice Address - Fax:256-237-6717
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21542174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051076321OtherBLUE CROSS AND BLUE SHIEL
AL000076321Medicaid
AL051076321OtherBLUE CROSS AND BLUE SHIEL
AL000076321Medicaid