Healthcare Provider Details

I. General information

NPI: 1598730376
Provider Name (Legal Business Name): JERRY WAYNE TERWILLIGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 04/30/2021
Certification Date: 04/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

IV. Provider business mailing address

1 GUTHRIE SQ JTERWILLIGER7934@DIRECT-GUTHRIE.ORG
SAYRE PA
18840-1625
US

V. Phone/Fax

Practice location:
  • Phone: 570-887-3070
  • Fax:
Mailing address:
  • Phone: 570-888-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number144861-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD028322E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier370017190
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRR MEDICARE PIN
# 2
Identifier0009221410001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
Identifier00702667
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 4
Identifier1598730376
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 5
IdentifierCC9269
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRR MEDICARE GROUP
# 6
IdentifierGU039851
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPA MEDICARE GROUP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: