Provider Demographics
NPI:1487927265
Name:TERRY I MERIDEN MD SC
Entity type:Organization
Organization Name:TERRY I MERIDEN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:I
Authorized Official - Last Name:MERIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACP FACN FACE
Authorized Official - Phone:309-673-1717
Mailing Address - Street 1:900 MAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1005
Mailing Address - Country:US
Mailing Address - Phone:309-673-1717
Mailing Address - Fax:309-673-7221
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-673-1717
Practice Address - Fax:309-673-7221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360586021207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058602Medicaid
IL792111124OtherRR MEDICARE
IL9000138OtherBCBS
IL792111124OtherRR MEDICARE