Provider Demographics
NPI:1952689945
Name:TERRY M. ECCLES, MD, LLC
Entity Type:Organization
Organization Name:TERRY M. ECCLES, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ECCLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-684-5015
Mailing Address - Street 1:72-LL WEST STAFFORD ROAD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076
Mailing Address - Country:US
Mailing Address - Phone:860-684-5015
Mailing Address - Fax:860-684-3749
Practice Address - Street 1:72-LL WEST STAFFORD ROAD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076
Practice Address - Country:US
Practice Address - Phone:860-684-5015
Practice Address - Fax:860-684-3749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037680208000000X
CT005863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty