Provider Demographics
NPI:1194764621
Name:TERRELL, MARK R (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:TERRELL
Suffix:
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 1:417 N ARBORETUM CIR
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-8703
Mailing Address - Country:US
Mailing Address - Phone:630-364-6564
Mailing Address - Fax:
Practice Address - Street 1:417 N ARBORETUM CIR
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-8703
Practice Address - Country:US
Practice Address - Phone:630-364-6564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089479207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089479Medicaid
IL036089479Medicaid
ILL88482Medicare ID - Type Unspecified