Provider Demographics
NPI:1770611832
Name:CHAN, TERENCE C (MD)
Entity type:Individual
Prefix:
First Name:TERENCE
Middle Name:C
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:2501 BUENA VISTA
Practice Address - Street 2:PMG PROVIDER RESOURCE GROUP
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87125
Practice Address - Country:US
Practice Address - Phone:505-923-5327
Practice Address - Fax:505-923-5305
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0593208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59876018Medicaid
NM59876018Medicaid
343526302Medicare PIN