MEDICARE: DR. TERREN BURGESS KOLES M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	35050061K	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699831693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERREN BURGESS KOLES M.D.

Provider Business Mailing Address
First Line	:	2912 SPRINGBORO RD
Second Line	:	SUITE 201
City	:	MORAINE
State	:	OH
Zip	:	45439-1674
Country	:	US
Telephone Number	:	937-885-1927
Fax Number	:

Provider Business Practice Location Address
First Line	:	2912 SPRINGBORO RD
Second Line	:	SUITE
City	:	MORAINE
State	:	OH
Zip	:	45439-1674
Country	:	US
Telephone Number	:	513-695-1468
Fax Number	:	513-695-2941

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	04/13/2012

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