Healthcare Provider Details

I. General information

NPI: 1144215856
Provider Name (Legal Business Name): TERRY W TALLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W IOWA ST
EVANSVILLE IN
47710-1721
US

IV. Provider business mailing address

201 W IOWA ST
EVANSVILLE IN
47710-1721
US

V. Phone/Fax

Practice location:
  • Phone: 812-424-2020
  • Fax: 812-424-3000
Mailing address:
  • Phone: 812-424-2020
  • Fax: 812-424-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01020881
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036085856
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number33096
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: