Healthcare Provider Details

I. General information

NPI: 1558226910
Provider Name (Legal Business Name): ANTONIO TERELL THOMAS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6805 STATE ROUTE 162
MARYVILLE IL
62062-8530
US

IV. Provider business mailing address

117 TIMBERWOOD LN
COLLINSVILLE IL
62234-6864
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-5019
  • Fax:
Mailing address:
  • Phone: 314-324-0165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041563515
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: