Healthcare Provider Details

I. General information

NPI: 1174058275
Provider Name (Legal Business Name): TOBY DYLAN TERWILLIGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3050
US

IV. Provider business mailing address

143 MAPLE HILL FARM RD
PENFIELD NY
14526-1713
US

V. Phone/Fax

Practice location:
  • Phone: 585-755-0192
  • Fax:
Mailing address:
  • Phone: 585-755-0192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number88520
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number88520
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number88520
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: