Provider Demographics
NPI:1699831693
Name:KOLES, TERREN BURGESS (MD)
Entity type:Individual
Prefix:DR
First Name:TERREN
Middle Name:BURGESS
Last Name:KOLES
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 1:2912 SPRINGBORO RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1674
Mailing Address - Country:US
Mailing Address - Phone:937-885-1927
Mailing Address - Fax:
Practice Address - Street 1:2912 SPRINGBORO RD
Practice Address - Street 2:SUITE
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1674
Practice Address - Country:US
Practice Address - Phone:513-695-1468
Practice Address - Fax:513-695-2941
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050061K208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2933179Medicaid
OHE29114Medicare UPIN