Provider Demographics
NPI:1104873017
Name:FRY, TERRY L (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:FRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MARINA DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-2410
Mailing Address - Country:US
Mailing Address - Phone:843-546-7272
Mailing Address - Fax:843-546-0277
Practice Address - Street 1:401 MARINA DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2410
Practice Address - Country:US
Practice Address - Phone:843-546-7272
Practice Address - Fax:843-546-0277
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14277207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC142777Medicaid
SC142777Medicaid
SCC880150281Medicare ID - Type Unspecified