Healthcare Provider Details

I. General information

NPI: 1700453453
Provider Name (Legal Business Name): TERRY ADAM BEAL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7979 DESTINY BLVD
FORT CAMPBELL KY
42223-5514
US

IV. Provider business mailing address

5979 DESERT STORM AVE
FORT CAMPBELL KY
42223-5514
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-4677
  • Fax:
Mailing address:
  • Phone: 270-798-4677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02006949A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: